Systems-based Practice Competency Research Articles

Resident Unions: Why Now and Will They Change Medical Education and Health Care?

During the COVID-19 pandemic, resident unions proliferated. While unionization resulted in increased compensation and benefits, the process of union negotiations may have created adversarial relationships between residents and their institutions' leadership, who residents depend on for supervision and the development of clinical expertise. Such adversarial relationships could affect the learning environment, which is critical to the delivery of high-quality care. In this commentary, the authors suggest that academic medical centers should offer residents an authentic seat at the institutional care delivery leadership table, ensuring residents' full participation in key organizational decisions. Doing so represents an alternative to unionization, with its potentially adversarial relationships, while still achieving a key goal of residents-to be included in the decisions that affect them and the care they provide. In this way, residents can use their unique understanding of the institutions' strengths and weaknesses to improve the quality of patient care and the learning environment. Such engagement can also help residents achieve competence in systems-based practice and provide a vital link between institutions and the patients and community they serve through health policy and advocacy activities.

Implementation of High-Value Care for Physical Therapy Residents Through Systems-Based Practice Curriculum Development: Case Report.

Systems-based practice is a core competency for physical therapy residents, best acquired through experiential learning. Peer health professions are further along than physical therapy in implementing curricula that support systems-based practice. Clinical and practice data in residency programs could provide for education in high-value care (HVC) as a foundation for systems-based practice. Our purpose was to develop and assess a HVC curriculum incorporating reflective practice to help residents achieve competency in systems-based practice. The Logic Model, which evaluates key components needed for success and sustainability, was used to identify resources for a curriculum in HVC. Two orthopedic physical therapy residents and 5 faculty mentors participated in didactic and mentoring sessions. A practice dashboard for each clinician was developed to facilitate resident-mentor discussions. Focus group input was used to refine the curriculum. The validated Systems Thinking Scale, the Quality Improvement Knowledge Application Tool Rubric, and the American Physical Therapy Association Residency Core Competency Score were used to assess residents' progress and to make comparisons to prior years' residents. The residents demonstrated increases in systems thinking and quality-improvement knowledge and improvements in clinical outcomes and practice efficiencies. Three themes emerged from semistructured interviews: challenges to HVC, current approach in HVC, and future-oriented thinking in HVC in practice. This study demonstrates that HVC activities and a personalized clinical dashboard in a physical therapy residency program can facilitate experiential learning of systems-based practice, a core competency for value-centered, inclusive practice.

Systems-Based Practice: Expert Perspectives on the Origin and Evolution of an Ambiguous Competency.

Systems-based practice (SBP) has been a core competency in graduate medical education in the United States since 1999, but it has been difficult to operationalize in residency programs due to its conceptual ambiguity. The authors explored the historical origin and subsequent development of the SBP competency from the perspective of individuals who were influential across critical phases of its implementation and ensuing development. The goal of this study was to elicit the history of SBP from the perspective of individuals who have expertise in it, and to use those findings to inform the current SBP construct. Between March and July 2021, 24 physicians, nurses, educators, and leaders in the field of SBP were individually interviewed about the origin and meaning of SBP as practiced in U.S. medical education using a semistructured guide. Individuals were selected based upon their influence on the origin or evolution of the SBP competency. Data were iteratively collected and analyzed using real-time analytic memos, regular adjudication sessions with the research team, and thematic analysis. Researchers identified themes from participants' perspectives and agreed upon the final results and quotations. Five themes were identified: SBP has many different definitions, SBP was intentionally designed to be vague, systems thinking was identified as the foundation of the SBP competency, the 6 core competencies established in the United States by the Accreditation Council for Graduate Medical Education were developed to be interdependent, and the SBP and practice-based learning and improvement competencies are uniquely related and synergistic. Interview data indicate that since its inception, SBP has been a nuanced and complex competency, resulting in a lack of mutually shared understanding among stakeholders. This deliberate historical examination of expert perspectives provides insight into specific areas for improving how SBP is taught and learned.

Lean Health Care Internships: A Novel Systems-Based Practice Education Program for Undergraduate Medical Students.

Given the United States' urgency for systemic-level improvements to care, advancing systems-based practice (SBP) competency among future physicians is crucial. However, SBP education is inadequate, lacks a unifying framework and faculty confidence in its teaching, and is taught late in the medical education journey. The Oklahoma State University Center for Health Systems Innovation (CHSI) created an SBP program relying on Lean Health Care for a framework and targeted medical students before their second year began. Lean curricula were developed (lecture and simulation) and a partnership with a hospital was secured for work-based practice. The CHSI developed a skills assessment tool for preliminary evaluation of the program. In June 2022, 9 undergraduate medical students responded to a Lean Health Care Internship (LHCI) presentation. Student SBP skills increased after training and again after work-based practice. All 9 students reported that their conceptualization of problems in health care changed "extraordinarily," and they were "extraordinarily" confident in their ability to approach another health care problem by applying the Lean method. The LHCI fostered an awareness of physicians as interdependent systems citizens, a key goal of SBP competency. After the internship concluded, the Lean team recommendations generated a resident-led quality assurance performance improvement initiative for bed throughput. The LHCI was effective in engaging students and building SBP skills among undergraduate medical education students. The levels of student enthusiasm and skill acquisition exceeded the Lean trainers' expectations. The researchers will continue to measure LHCI's effect on students' rotation experiences to better evaluate the long-term benefit of introducing SBP concepts earlier in medical education. The program's success has spurred enthusiasm for continued collaboration with hospital and residency programs. Program administrators are exploring how to broaden access.

The Systems-Based Practice Competency: An Innovative Model to Achieving Class-Wide Proficiency in a Pain Medicine Fellowship.

One of the ACGME's six core competencies, systems-based practice (SBP), is difficult to interpret and developing proficiency over a one-year fellowship poses a challenge. Given the implications that successful SBP can have on pain medicine, it is especially important for fellows to focus on this competency during their training. Here, we propose a way to implement effective SBP into a pain medicine fellowship and the impact it may have within the larger health care system.

Breaking Down Silos Between Medical Education and Health Systems: Creating an Integrated Multilevel Data Model to Advance the Systems-Based Practice Competency.

The complexity of improving health in the United States and the rising call for outcomes-based physician training present unique challenges and opportunities for both graduate medical education (GME) and health systems. GME programs have been particularly challenged to implement systems-based practice (SBP) as a core physician competency and educational outcome. Disparate definitions and educational approaches to SBP, as well as limited understanding of the complex interactions between GME trainees, programs, and their health system settings, contribute to current suboptimal educational outcomes elated to SBP. To advance SBP competence at individual, program, and institutional levels, the authors present the rationale for an integrated multilevel systems approach to assess and evaluate SBP, propose a conceptual multilevel data model that integrates health system and educational SBP performance, and explore the opportunities and challenges of using multilevel data to promote an empirically driven approach to residency education. The development, study, and adoption of multilevel analytic approaches to GME are imperative to the successful operationalization of SBP and thereby imperative to GME's social accountability in meeting societal needs for improved health. The authors call for the continued collaboration of national leaders toward producing integrated and multilevel datasets that link health systems and their GME-sponsoring institutions to evolve SBP.

How Should Health Systems Science Promote Health Systems' Sustainability?

An expanded sustainability framework for health systems science (HSS) could promote health systems' capacity to deliver efficient, effective care for patients and to care for the planet by decreasing emissions and solid waste while cutting costs. This framework aligns well with the HSS mission to reform curricula and practice and has direct implications for patient care and systems-based practice competency development. Training clinicians to think critically about health system function, resilience, and sustainability will help prepare trainees to lead, innovate, and transform current health systems to prioritize planetary health, resource stewardship, and patient outcomes in a circular supply chain with low emissions.

Viewpoint on Milestones for Fellowship Training in Movement Disorders.

Viewpoint on Milestones for Fellowship Training in Movement Disorders.

Developing Telemedicine Curriculum Competencies for Graduate Medical Education: Outcomes of a Modified Delphi Process.

Telemedical applications have only recently begun to coalesce into the field of telemedicine due to varying definitions of telemedicine and issues around reimbursement. This process has been accelerated by the COVID-19 pandemic and the ensuing expansion of telemedicine delivery. This article demonstrates the development of a set of proposed competencies for a telemedicine curriculum in graduate medical education. A modified Delphi process was used to create a panel of competencies. This included a systematic review of the telemedicine literature through November 2019 to create an initial set of competencies, which were analyzed and edited by a focus group of experts in January 2020. Initial competencies were distributed in a series of 3 rounds of surveys to a group of 23 experts for comments and rating from April to August 2020. Competencies that obtained a score of 4.0 or greater on a 5-point Likert scale in at least 2 rounds were recommended. Fifty-five competencies were developed based on the systematic review. A further 32 were added by the expert group for a total of 87. After 3 rounds of surveys, 34 competencies reached the recommendation threshold. These were 10 systems-based practice competencies, 7 professionalism, 6 patient care, 4 practice-based learning and improvement, 4 interpersonal and communication skills, and 3 medical knowledge competencies. Half (17/34) of the competencies approved by the focus group and surveyed expert panel pertained to either systems-based practice or professionalism. Both categories exhibit more variation between telemedicine and in-person practice than other categories. The authors offer a set of proposed educational competencies that can be used in the development of curricula for a wide range of providers and are based on the best evidence and expert opinion available.

Evolving the Systems-Based Practice Competency in Graduate Medical Education to Meet Patient Needs in the 21st-Century Health Care System.

Medical education is increasingly recognizing the importance of the systems-based practice (SBP) competency in the emerging 21st-century U.S. health care landscape. In the wake of data documenting insufficiencies in care delivery, notably in patient safety and health care disparities, the Accreditation Council for Graduate Medical Education created the SBP competency to address gaps in health outcomes and facilitate the education of trainees to better meet the needs of patients. Despite the introduction of SBP over 20 years ago, efforts to realize its potential have been incomplete and fragmented. Several challenges exist, including difficulty in operationalizing and evaluating SBP in current clinical learning environments. This inconsistent evolution of SBP has compromised the professional development of physicians who are increasingly expected to advance systems of care and actively contribute to improving patient outcomes, patient and care team experience, and costs of care. The authors prioritize 5 areas of focus necessary to further evolve SBP: comprehensive systems-based learning content, a professional development continuum, teaching and assessment methods, clinical learning environments in which SBP is learned and practiced, and professional identity as systems citizens. Accelerating the evolution of SBP in these 5 focus areas will require health system leaders and educators to embrace complexity with a systems thinking mindset, use coproduction between sponsoring health systems and education programs, create new roles to drive alignment of system and educational goals, and use design thinking to propel improvement efforts. The evolution of SBP is essential to cultivate the next generation of collaboratively effective, systems-minded professionals and improve patient outcomes.

Evaluation of a Quality Improvement Experience for Family Medicine Clerkship Students.

There is emphasis on systems-based practice competencies and quality improvement (QI) training in postgraduate medical education. However, we lack effective approaches to provide experiences in these areas during undergraduate medical education. To address this, we developed a novel approach to providing didactic and experiential learning experiences in QI during a third-year family medicine clerkship. We implemented and evaluated a QI curriculum combining self-directed learning with real-world experience to increase knowledge and confidence in the plan-do-study-act (PDSA) process for family medicine clerkship students. Students collaborated and presented their change ideas in a "Shark Tank" format for practice leaders at the end of their rotation. We used pre- and postcurriculum surveys to assess knowledge of and comfort with completing QI projects. Three hundred eighty-nine students completed precurriculum surveys and 242 completed postcurriculum surveys. Pre- and postlearning evaluations revealed an increase in agreement or strong agreement with self-reported understanding of specific QI topic areas of 50%. Almost all (91.3%) reported feeling confident or reasonably confident in their ability to create change in health care after exposure to the curriculum, compared with 66.3% in the precurriculum survey. One-third of students (34%) reported intent to complete the Institute for Healthcare Improvement Open School curriculum in QI. Self-directed learning about QI, combined with practice observation, small-group discussion and presentation in a Shark Tank format was effective and engaging for learners. Students had limited preexisting knowledge of QI principles, suggesting a need for preclinical exposure to this topic. The family medicine clerkship provides an ideal environment for teaching QI.

Multicenter Survey of Resident Education in Professional Development and the Business of Orthopaedics: Are Residents Ready for Transition to Practice?

Background Systems-based practice is a core competency of orthopaedic residency, yet there is no defined curriculum to address this area, which may leave residents with gaps in knowledge. Objective The aim of this study was to assess residents’ understanding of systems-based practice and interest in incorporating these principles into curricula. Methods In 2018 a survey was emailed to residents in programs across the United States evaluating comprehension in systems-based practice, and interest in specific domains of curriculum development: personal finance, value of orthopaedics, practice dynamics, transition to practice, work life balance, research, professional development, leadership development, international medical work, and law. Residents were categorized into subgroups based on years of training: junior (1-3) and senior (4-5), and nonparametric chi-squared analysis was performed between the groups. Results Of 275 residents surveyed, 151 completed the survey for an overall response rate of 55%. Self-rated understanding of systems-based practice was statistically identical (p=1.00) between junior and senior residents; 91.4% of both groups indicated low comprehension of the systems-based practice competency. There was strong interest by the majority of respondents in further training in many domains. When subcategorized as junior and senior residents, the only significant differences in interest were in professional development (p=0.04) and transition to practice (p = 0.01) domains, with more junior residents expressing strong interest in further training in these topics. Conclusions This study indicated that there is a gap in resident education in systems-based practice and that orthopaedic residents are interested in the enhancement of education in this domain.

Systems-Based Practice: Time to Finally Adopt the Orphan Competency.

Systems-Based Practice: Time to Finally Adopt the Orphan Competency.

General Internists as Change Agents: Opportunities and Barriers to Leadership in Health Systems and Medical Education Transformation.

Health systems are increasingly engaging in mission development around the quadruple aim of patient experience of care, population health, cost of care, and work-life balance of clinicians. This integrated approach is closely aligned with the education principles and competencies of health systems science (HSS), which includes population health, high-value care, leadership, teamwork, collaboration, and systems thinking. Influenced by health outcomes research, the systems-based practice competency, and the Clinical Learning Environment Review, many medical schools and residency programs are taking on the challenge of comprehensively incorporating these HSS competencies into the education agenda. General internal medicine physicians, inclusive of hospitalists, geriatricians, and palliative and primary care physicians, are at the frontlines of this transformation and uniquely positioned to contribute to and lead health system transformation, role model HSS competencies for trainees, and facilitate the education of a new workforce equipped with HSS skills to accelerate change in healthcare. Although GIM faculty are positioned to be early adopters and leaders in evolving systems of care and education, professional development and changes with academic health systems are required. This Perspective article explores the conceptualization and opportunities to effectively link GIM with healthcare and medical education transformation.

PILOTING AN INTERPROFESSIONAL GERIATRICS COURSE FOCUSED ON SYSTEMS-BASED PRACTICE

Health professionals must be able to work together in the care of older adults to provide competent, value-based care within dynamic healthcare systems. Previous studies cite the need for health professions education addressing systems-based competencies and the interconnected components of health and aging services. With an aim to provide a foundation for systems-based interprofessional practice in the care of older adults, an academic medical center piloted a competency-based curriculum introducing different settings of care for older adults and exploring special topics in geriatric patient care and gerontology. Applying a framework of health and aging services, interprofessional faculty developed a curriculum delivered over six one-hour sessions during the Spring 2019 semester. Session topics included dementia care, end-of-life care, medication safety, activity, and financial and regulatory considerations across the continuum of care. Teaching strategies included didactics, case-based discussions, online reflection questions, shadowing of geriatric encounters in clinic and long-term care settings, and student presentations of a patient case. Post-session evaluation surveys were administered electronically to measure knowledge, skills and confidence using Likert-scale and open-ended questions. Eleven health professions students (medical [n=6], physician assistant [n=3], physical therapy [n=2]) participated. Preliminary findings show improved knowledge about healthcare and community-based options for older adults, value-based care, and the driving forces affecting health care delivery. Analysis of qualitative feedback identified key themes related to teaching methods, course materials, and course improvement opportunities. Interprofessional faculty collaboration can lead to quality health professions student training and increase competency in systems-based practice in the care of older adults.

Ability of Ophthalmology Residents to Self-Assess Their Performance Through Established Milestones

Accurate self-assessment is an important aspect of practice-based learning and improvement and a critical skill for resident growth. The Accreditation Council for Graduate Medical Education mandates semiannual milestones assessments by a clinical competency committee (CCC) for all ophthalmology residents. There are six core competencies: patient care (PC), medical knowledge, systems-based practice, practice-based learning and improvement, professionalism, and interpersonal communication skills. These competencies are assessed by the milestones rubric, which has detailed behavioral anchors and are also used for trainee self-assessments. This study compares resident self-assessed (SA) and faculty CCC milestones scores. Residents completed milestones self-assessments prior to receiving individual score reports from the CCC. Correlation coefficients were calculated comparing the SA and CCC scores. In addition, statistical models were used to determine predictors of disparities and differences between the SA and CCC scores. Wilmer Eye Institute, Johns Hopkins Hospital. Twenty-one residents in the Wilmer Ophthalmology Residency program from July 2014 to June 2016. Fifty-seven self-assessments were available for the analysis. For each resident's first assessment, SA and CCC scores were strongly correlated (r ≥ 0.6 and p < 0.05) for four milestones, and not correlated for the remaining 20 milestones. In multivariable models, the SA and CCC scores are less disparate for medical knowledge and systems-based practice competencies compared to practice-based learning and improvement. Higher year of training, PC and professionalism competencies were predictive of statistically significant resident overestimation of scores relative to the CCC. In addition, higher CCC scores predicted statistically significant lower SA-CCC disparities and differences. SA-CCC differences did not lower to a significant extent with repeated assessments or modification to the end-of-rotation evaluation forms. Self-assessments by ophthalmology residents are not well-correlated with faculty assessments, emphasizing the need for improved and frequent timely feedback. Residents have the greatest difficulty self-assessing their professionalism and PC competency. In general, senior residents and underperforming residents have more inaccurate self-assessments.

A Simulation-Based Workshop to Improve Residents' Collaborative Clinical Practice.

The Accreditation Council for Graduate Medical Education expects residents to attain competency in systems-based practice by advocating for quality patient care, working in interprofessional teams, and implementing system solutions to prevent errors. Diabetes in pregnancy was identified as an area for improvement through comprehensive interdisciplinary and interprofessional care. An interdisciplinary and interprofessional workshop was created by 3 regional academic institutions to improve collaborative practice, clinical knowledge, and clinical judgment of residents. A workshop consisting of 4 clinical simulation stations for ultrasound assessment, glycemic control, hyperglycemic emergencies, and macrosomia complications was designed to address gaps in quality of care. Workshop participants were residents from 6 programs and students in nursing, pharmacy, and sonography. Attitude and clinical knowledge were measured preworkshop and postworkshop, and at 3-month and 6- to 7-month follow-up. There were increases in average clinical knowledge scores across time points from residents: 56.4% preworkshop, 64.8% postworkshop, 66.0% at 3-month follow-up, and 68.1% at 6- to 7-month follow-up. Additionally, participants reported positive attitudes toward interprofessional education and indicated high overall satisfaction. Residents demonstrated improved knowledge and attitudes toward interprofessional training after participating in a large-scale simulation workshop focused on the care of patients with diabetes in pregnancy.

A Systems-Based Practice Curriculum in Orthopaedics: Successes and Challenges Moving Forward.

Teaching and assessment of the systems-based practice competency have been a challenge for many educators in graduate medical education. Previous research done at our institution demonstrated a marked inconsistency across institutions in educational content, methods of delivery, and performance assessment. As a result, we developed a 2-week health systems curriculum for orthopaedic surgery residents. A 2-week health systems rotation was developed during which postgraduate year (PGY)-1 residents were excused from their normal clinical duties. Residents followed patients as observers of the health-care system, challenged to view health care through the eyes of the patient and to identify what could be done individually and collectively to provide a better and safer experience. Additional learning experiences were designed on the basis of our literature review. At the end of the rotation, residents discussed and provided a written summary of their experiences and completed an anonymous evaluation. Using a Likert scale (1 to 10), residents were asked if the experience was educational and whether it was it additive to their undergraduate medical education for each of the 9 educational areas. The mean responses for all 9 educational areas were 8.2 for whether the experience was educational and 8.3 for whether it was it additive to participants' undergraduate medical education. Feedback from residents indicated that they found the course very helpful and that it inspired them to consider how they could "create overdue and necessary changes in our health-care system." Our health systems rotation in PGY-1 has been a valuable learning experience for the residents and has created a foundation on which to build in subsequent years of residency.

Competency Crosswalk: A Multispecialty Review of the Accreditation Council for Graduate Medical Education Milestones Across Four Competency Domains.

To identify common and overlapping themes among the interpersonal and communication skills (ICS), practice-based learning and improvement (PBLI), professionalism (PROF), and systems-based practice (SBP) milestones of the transitional year and 26 specialties. In May 2017, milestones were accessed from the Accreditation Council for Graduate Medical Education specialties website. A thematic analysis of the ICS, PBLI, PROF, and SBP milestones was performed to determine unique and common themes across these competencies and across specialties. Keywords from the common program requirements were initially applied as codes to the milestones. Codes were then grouped into common themes. Twenty-two themes were identified: 15 (68%) were unique to a given competency (3 related to ICS, 4 related to PBLI, 5 related to PROF, and 3 related to SBP), and 7 (32%) appeared in the milestones of more than one core competency. Eleven themes (50%) were used by 20 or more specialties, and 6 themes (27%) by 10 or fewer specialties. No theme was present across all specialties. The ICS, PBLI, PROF, and SBP milestones contain multiple themes with areas of overlap among these four competencies and substantial variability across specialties. This variability may create differential expectations of residents across specialties, complicate faculty development, and make sharing assessment tools difficult. The thematic analysis provides important insights into how individual specialties interpret and operationalize the ICS, PBLI, PROF, and SBP competency domains and can inform future revisions of milestones to enable harmonization and shared understanding of these competencies across specialties where appropriate.

Core Entrustable Professional Activities for Entry Into Residency: Curricular Gap or Unrealistic Expectations?

Core Entrustable Professional Activities for Entry Into Residency: Curricular Gap or Unrealistic Expectations?