System Leaders Research Articles

Optimising school leadership development for 21st-century learning: An in-depth analysis of South African private secondary schools in KwaZulu-Natal

There have been significant and rapid improvements in information and communication technology (ICT) since the early 1990s. Subsequent global changes have increased with the onset of the Fourth Industrial Revolution and have dictated pedagogical transformation. Many countries have moved from traditional approaches of education to 21st-century Learning (21CL). 21CL is ICT-aligned, inquiry-based, and includes the development of affective abilities. School leadership influences all structures and individuals directly in a school. It has the potential to be one of the cornerstones of the paradigm shift to 21CL. I investigated how school leadership is developed to facilitate 21CL and how it can be improved. I required quantitative and qualitative data to achieve the research objectives. Therefore, I adopted a mixed methods research approach that is underpinned by the positivist and interpretivist paradigms. I used a case study design. The data collection methods I employed were questionnaires, semi-structured interviews, and focus group interviews. Phase one of the research involved the quantitative data collection from twenty-five schools, of which five schools were purposely sampled for the second qualitative phase. The use of transformational leadership, strategic leadership, system leadership, and ecological leadership in enacting 21CL featured prominently in the reviewed literature. However, the research findings show that, largely, these four leadership theories were not incorporated in leadership development in South Africa. The results also show that school leadership development specifically designed for 21CL, was limited. The leadership training that is available focused more on administrative tasks instead of on leadership theories and skills to facilitate 21CL. I recommend that further research be conducted in both private and public schools in other South African provinces.

Transitional Care Support for Medicaid-Insured Patients With Serious Mental Illness: Protocol for a Type I Hybrid Effectiveness-Implementation Stepped-Wedge Cluster Randomized Controlled Trial.

People diagnosed with a co-occurring serious mental illness (SMI; ie, major depressive disorder, bipolar disorder, or schizophrenia) but hospitalized for a nonpsychiatric condition experience higher rates of readmissions and other adverse outcomes, in part due to poorly coordinated care transitions. Current hospital-to-home transitional care programs lack a focus on the integrated social, medical, and mental health needs of these patients. The Thrive clinical pathway provides transitional care support for patients insured by Medicaid with multiple chronic conditions by focusing on posthospitalization medical concerns and the social determinants of health. This study seeks to evaluate an adapted version of Thrive that also meets the needs of patients with co-occurring SMI discharged from a nonpsychiatric hospitalization. This study aimed to (1) engage staff and community advisors in participatory implementation processes to adapt the Thrive clinical pathway for all Medicaid-insured patients, including those with SMI; (2) examine utilization outcomes (ie, Thrive referral, readmission, emergency department [ED], primary, and specialty care visits) for Medicaid-insured individuals with and without SMI who receive Thrive compared with usual care; and (3) evaluate the acceptability, appropriateness, feasibility, and cost-benefit of an adapted Thrive clinical pathway that is tailored for Medicaid-insured patients with co-occurring SMI. This study will use a prospective, type I hybrid effectiveness-implementation, stepped-wedge, cluster randomized controlled trial design. We will randomize the initiation of Thrive referrals at the unit level. Data collection will occur over 24 months. Inclusion criteria for Thrive referral include individuals who (1) are Medicaid insured, dually enrolled in Medicaid and Medicare, or Medicaid eligible; (2) reside in Philadelphia; (3) are admitted for a medical diagnosis for over 24 hours at the study hospital; (4) are planned for discharge to home; (5) agree to receive home care services; and (6) are aged ≥18 years. Primary analyses will use a mixed-effects negative binomial regression model to evaluate readmission and ED utilization, comparing those with and without SMI who receive Thrive to those with and without SMI who receive usual care. Using a convergent parallel mixed methods design, analyses will be conducted simultaneously for the survey and interview data of patients, clinicians, and health care system leaders. The cost of Thrive will be calculated from budget monitoring data for the research budget, the cost of staff time, and average Medicaid facility fee payments. This research project was funded in October 2023. Data collection will occur from April 2024 through December 2025. Results are anticipated to be published in 2025-2027. We anticipate that patients with and without co-occurring SMI will benefit from the adapted Thrive clinical pathway. We also anticipate the adapted version of Thrive to be deemed feasible, acceptable, and appropriate by patients, clinicians, and health system leaders. ClinicalTrials.gov NCT06203509; https://clinicaltrials.gov/ct2/show/NCT06203509. DERR1-10.2196/64575.

Envisioning the sustainable and climate resilient hospital of the future

ObjectivesThis study aims to create a vision of the future hospital to help healthcare leaders understand how changes in society and the healthcare system, compounded by climate change, could affect future hospital estate. Study designThe study is part of a larger project based on participatory backcasting aimed at providing integrated strategies for transitioning to a zero-carbon future and adapting to existing climate change through improved asset management. MethodsThe data presented in this paper were collected during a full-day workshop to construct the vision of the future hospital in 2050. A multidisciplinary team of 19 participants participated in the discussions. A six-phase thematic analysis was applied to the data to develop the narrative vision and graphic recording. ResultsThe healthcare system is undergoing transformative changes due to evolving healthcare delivery, patient expectations, emerging technologies, climate change, and sustainability. However, current hospital strategies often fail to consider the interrelationship between the hospital estate and its socio-environmental context. Policymakers, healthcare system leaders, and hospital leaders need a clear vision of the hospital of the future to implement transformational strategies. ConclusionsHealthcare transformations require shifting from traditional centralised hospitals to a more flexible, distributed model. Healthcare leaders need to proactively assess how hospitals respond to current and future hazards and consider the impacts within the context of integrated and dispersed healthcare delivery. To address this, a systematic approach to modelling hazards and evaluating design or upgrading options is essential to mitigate the transfer of climate-related risks within healthcare systems.

Contexts and complexities: a realist evaluation of integrated care system leadership.

This paper presents a realist evaluation of leadership within an integrated care system (ICS) in England. This paper aims to examine which aspects of leadership are effective, for whom, how and under what circumstances. Realist evaluation methodology was used, adopting prior realist review findings as the theoretical framework to refine explanations of how and why leadership within an ICS is effective. Between January and November 2023, 23 interviews with ICS leaders took place, alongside 7 meeting observations and documentary analysis. The Realist And Metanarrative Evidence Syntheses: Evolving Standards (RAMESES) guidance informed the study design, conduct and reporting. The findings highlight two overarching infrastructural contexts influencing leadership in ICSs: the impact of the post-COVID-19 pandemic legacy and the differences between health and social care regulatory and financial environments. Findings demonstrate that ICS leaders identified a strong sense of purpose as crucial for guiding decisions and creating a psychologically safe environment for open, honest discussions, fostering calculated risk-taking. Whilst a shared vision directed priority setting, financial pressures led to siloed thinking. Leadership visibility was linked to workforce morale, with supportive leadership boosting morale amidst evolving ICS landscapes and confidence in data-driven decisions supported prevention activities. However, financial constraints hindered responsiveness and innovation in addressing health inequalities. By examining ICS leadership post-COVID-19 pandemic and amidst varying regulatory and financial environments, this study contributes to the emerging literature on systems leadership and offers practical guidance for leaders navigating the complexities of integrated care.

NHS action on social and economic development in England: Vague national policy expectations

Under recent reforms to the National Health Service (NHS) in England, NHS organizations have been given new objectives to contribute to social and economic development. Health systems in other high-income countries are pursuing related approaches. This paper analyses national policy documents to understand the framing of the NHS's new policy priorities on social and economic development. We focus on the role of NHS integrated care systems—area-based planning bodies responsible for managing NHS resources and coordinating local services. National policy is vague about what social and economic development means in practice. There is limited guidance on which approaches local organizations should prioritize, and which organisations are responsible for implementation. Greater clarity from national policymakers and an overarching framework to guide local action is needed to reduce the risk of inaction, poorly targeted interventions, and missed opportunities for learning and evaluation. Policymakers and health system leaders also need to be realistic about the limits of local action given the importance of national public policy choices in shaping the social determinants of health. Coordinated policy action and investment across government is needed to address underlying social and economic conditions.

Integrating the Airway Lead structure into a large healthcare system to appraise the landscape of airway management resources

Airway Leads are clinicians who guide safe airway management institutionally and act as liaisons between the evolving airway management landscape and bedside clinicians. Internationally, resources produced by Airway Leads Networks aid clinicians in establishing emergency airway management protocols and making difficult airway equipment decisions. The creation of an Airway Leads Network within the United States' multi-payer healthcare system is ongoing, spearheaded nationally by groups such as the Society for Airway Management. We aimed to build a committee of airway leaders across the Yale New Haven Health system and to leverage this committee to appraise the airway equipment and personnel resources throughout the system. We identified key stakeholders in airway management across the healthcare system and administered a quality improvement survey to members of the assembled committee querying their knowledge of the availability of airway management devices. The dataset was gathered from 14 airway management leaders identified across 4 surgical facilities, 6 emergency departments and 5 medical intensive care units at 8 hospitals and hospital campuses within the Yale New Haven Health system. Equipment available in greater than 75 % of locations included hyperangulated and standard geometry videolaryngoscopes, rigid tracheal tube stylets, tracheal tube introducers, flexible intubation scopes, scalpels and waveform capnography. Equipment available in 25 % to <75 % of locations included emergency invasive airway kits, wheeled airway towers or airway boxes, intubating oral airways, airway exchange and Aintree catheters, intubation-capable supraglottic airways, and awake intubation supplies. Glidescope (Verathon) was the most common videolaryngoscope and flexible intubation scope, and Aura (Teleflex) was the most common intubation-capable supraglottic airway available. The initiative illustrated the feasibility and utility of developing a committee of airway leaders in a large health system. While all locations had access to a requisite array of airway management devices, there was variation in the availability and brand of individual airway equipment.

Integrating community health workers into HIV care clinics: a qualitative study with health system leaders and clinicians in the Southern United States

BackgroundCommunity health workers (CHWs) can support patient engagement in care for a variety of health conditions, including HIV. This paper reports on the experiences of HIV clinics and health departments that integrated CHWs into their health systems as part of a capacity-building initiative to address HIV-related disparities in the United States.MethodsSemi-structured interviews were conducted with key informants (n = 14) in two Ryan White HIV/AIDS program jurisdictions: Mississippi (jurisdiction covers the entire state) and the city of New Orleans, Louisiana. This work was part of a larger evaluation of an initiative that used a Learning Collaborative model to facilitate the implementation of evidence-informed interventions to address HIV care continuum gaps in four jurisdictions. The two jurisdictions that focused on integrating CHWs into HIV care clinics and support service agencies were selected for this sub-analysis. Interview participants included HIV clinic leaders and staff, health department leaders, and other Learning Collaborative leaders. Interview transcripts were coded and analyzed for themes related to the acceptability, feasibility, and perceived impact of CHW integration.ResultsOverall, participants expressed interest in having support from CHWs at HIV clinics and service agencies to assist with patient retention and engagement efforts. However, there were challenges integrating CHWs into existing systems (e.g., gaining access to electronic health records, changing policies to conduct home visits, and clarifying roles and scope of work). Negotiating contracts and accessing funding for CHW positions presented major challenges that often contributed to turnover and conflicts around scope of practice. When health departments leveraged existing funding streams to support CHW positions, the clinics and agencies where the CHWs worked had limited flexibility over the hiring process.ConclusionsOur findings reinforce the value and acceptability of CHWs as part of the workforce in HIV clinical and support service settings; however, integrating CHWs into clinics and service agencies required effort. Training the CHWs was not sufficient; other staff and clinicians had to understand the role of CHWs to facilitate their integration into health systems. Resources are needed to support organizations in incorporating CHWs effectively, and long-term, flexible sources of funding are necessary for these positions.

Co-producing evidence to inform universal health coverage implementation in Ireland: 2019-2024

Abstract Background In 2017, Ireland’s parliamentary health committee published a ten-year health reform plan, entitled Sláintecare, with the aim of delivering universal healthcare. Endorsed by government in 2018, progressing Sláintecare remains government policy in 2024. In 2019, Prof Burke was awarded public funding to co-produce knowledge for the design and implementation of the regions, a key aspect of Sláintecare. In 2020, with the arrival of COVID-19, regional reform was paused and the research pivoted to capture the learning from the COVID-19 health system response to inform Sláintecare. In 2022/3, the research returned to focus on the regions. Methods Foundations’ research resulted in 14 peer-reviewed publications between 2019 and 2023. These were mixed-methods using qualitative and quantitative data and analysis. Coproduction with health system leaders that were devising and implementing the regions and the COVID-19 health system response underpinned the research. Results There are 14 academic publications from the Foundations Research (2019-2023). At the core of co-production is trust and good working relationships. Co-producing research with senior policy makers and implementers has benefits and drawbacks. The benefits include access to resources and data and that the data and knowledge generated are more likely to be adopted. Drawbacks include control over areas researched, denial of access to data and lack of openness to research findings. Producing controversial findings, unpopular with government, minister or health system leaders can also lead to difficulties for the research team. Discussion/conclusions Details of the coproduction process with senior health system and policy leaders will be presented. It will detail specific examples of the research which were initiated by the health system and those that came from the academic research team. It will give examples of how the research influenced the policy making and implementation processes. Key messages • Co-producing research between academics and health system and policy leaders leads to better use of evidence. • Trust and good workign relationships are key to co-producing research that is used in policy making and implementation processes.

9.D. Practice session: Luton, a Marmot town – Lessons from using a whole-system approach to tackle health equity

Abstract Objective To share learnings from our Health Equity Town journey, including opportunities and challenges. To allow stimulating discussion on whole system approaches to health inequalities and the social determinants of health. To include discussion on where and how public health influences or leads, the importance of impact measures, and of shared vision. Added value Luton’s 2040 strategy, and being a health equity town, are long term visions. It has been 18 months since we launched Luton’s health equity ambition, and during that time we have taken great strides forward in how we deliver against the Marmot principles and create a movement around health equity in Luton. Organisations nationally and internationally are grappling with approaches to doing this. This workshop will provide an opportunity to discuss some of the key learnings, challenges and opportunities so far in taking this approach, and how to continue to maintain momentum and buy in across sectors at local level. The workshop will include discussion on the following: 1. Taking a whole-system approach to health inequalities - working across system leaders and strategic partners including health, care, voluntary sector, businesses, housing, police and others, as well as across the local authority departments. This takes clear articulation of the problem and actions, as well as clarity on where public health professionals are most effective to support, influence, and lead. 2. There is increasing recognition of the building blocks of health and the importance of ensuring action to improve health outcomes is taken across the whole system to tackle health inequalities - including employment, education, and housing. Discussion on specific actions being taken in some of these areas to tackle health inequalities as part of the health equity town approach. 3. Working with the community to understand health inequalities. 4. How we will measure progress. 5. The concept of proportionate universalism is now well known, however making this a reality is a challenge. 6. East London Foundation Trust, the mental health provider in Luton, is also embedding Marmot Policy objectives across the Trust, and is a key partner in Luton. Work is underway to establish projects with joint aims such as skills passport to increase employment in mental health service users. Format Presentation followed by opportunity for question and answer and discussion with panel. Key messages • Whole system approaches to tackling health equity are possible through shared vision and coordinated approach. • Action across the building blocks of health is vital, the complex and long term nature is challenging.

How to not revert to type: learnings from the pandemic response for universal health system reform

Abstract Background Understanding of the opportunities and learnings for health system change that have arisen during the pandemic is still emerging. Situated in the Irish health reform context of Sláintecare, the programme which aims to deliver universal, integrated healthcare, this study set out to generate evidence on the processes that impacted access to universal, integrated care during COVID-19, with a view to informing universal health system reform and implementation. Methods The study, which is qualitative, was underpinned by a co-production approach with Irish health system leadership. Semi-structured interviews were conducted with 16 health system professionals (including managers and frontline workers) from a range of responses to explore their experiences during the pandemic. Following thematic analysis, a complexity-informed approach guided the interpretation of the findings. Results A range of factors facilitated better access to integrated care during the crisis, falling under three key themes (1) nurturing whole-system thinking through a clear, common goal and shared information base; (2) harnessing, sharing and supporting innovation; and (3) prioritizing trust and relationship-building in a human-centred health system. Conclusions Alongside establishing health system structures, we must also incorporate alternative approaches to reform that recognise the value of shared sense-making in an interdependent system, while also allowing for innovation, exploration and learning; and acknowledging the role of social dynamics in driving change.

The NHS London Legacy and Health Equity Partnership: Evaluation of an equity lens framework

Abstract Background Disparities in COVID-19 vaccination uptake emphasised stark inequalities linked to ethnicity and deprivation, highlighting lack of trust and access barriers. London health leaders committed to create a community-centred legacy through the development of the NHS Legacy and Health Equity Partnership (LHEP); A novel 2-year programme aiming to close the equity gap in vaccinations, screening and access to health, focused on underserved communities, delivered in collaboration with London partners and communities. LHEP focused on 12 unique programmes with a key role of system leadership. Outputs included 15 reports, 6 conference presentations, 7 academic publications, 6 community workshops and 5 toolkits including development of an overarching LHEP framework aiming for long-term legacy. Methods An evaluation was designed to assess the benefits and limitations of the programme and framework through 16 semi-structured interviews and 5 focus groups delivered with key stakeholders. Ethical approval was obtained from the UKHSA Research Ethics Group. Data was coded inductively and drawn into themes. Results LHEP was said to add value through a) a dedicated team championing health equity and visible focus of leadership within the equity space b) fostering community engagement enabling dialogue between health systems and communities c) advocating co-production, building trust, focusing on communities in vulnerable circumstances d) programme innovation and agility d) drawing from COVID-19 lessons and disseminating learning. Interviewees stressed a legacy beyond vaccinations, establishing London as a blueprint for others. Conclusions Lessons were drawn into the ‘LHEP Approach for Health Equity’, a concise framework to guide partners to embed health equity, gathering 4 key tenets to ensure ‘no community is left behind’; data, evidence and learning; commitment from leaders and strong partnerships, allow for innovation and consider sustainability and communities at the centre. Key messages • Legacy and Health Equity Partnership is a 2-year multistakeholder programme aiming to tackle inequalities for the diverse communities of London that built evidence and led system change. • Evaluation stressed the impact of establishing London as a blueprint to follow and a framework to guide and support partners striving for health equity.

BE-SAFE: Intervention to reduce benzodiazepine and sedative hypnotics in elderly with sleep problems

Abstract Introduction Benzodiazepine and sedative hypnotics (BSH) may have significant adverse effects and associated costs, especially in older adults: increased risk of falls, fractures, hospitalisations, impaired functioning, delirium, cognitive impairment and mortality. Addressing BSH overuse is therefore an urgent priority to improve patient safety in Europe. Objectives To present the 5-year research project BE-SAFE, funded by the European Commission (HORIZON Europe) and by the Swiss State Secretariat for Education, Research, and Innovation. BE-SAFE aims to improve patient safety by addressing knowledge and practice gaps related to the reduction of BSH used by older adults for sleep problems. Methods BE-SAFE involves seven inter-related work packages and six European countries (Belgium, Greece, Norway, Poland, Spain and Switzerland) as well as experts from Canada; it proposes an interdisciplinary and inter-sectorial approach with experts in guidelines, implementation, dissemination, case studies, geriatrics and sleep. BE-SAFE will develop an intervention comprising trustworthy clinical guidelines, implementation recommendations and patient-centred material. This intervention will be tested in a cluster randomized controlled trial; 470 patients (65 years old and above) and 62 prescribing physicians in hospital and outpatient settings. Results BE-SAFE is expected to result in reduction of BSH use. Its toolkit, encompassing setting-specific implementation recommendations, will enable healthcare professionals (HCPs) to identify, evaluate and prevent risks of BSH use. The BE-SAFE approach could also be expanded to cover reduction of use of other medications. Conclusions Through BE-SAFE, patient safety is expected to improve; BE-SAFE project will reach a wide-ranging audience, including general population, informal carers, older adults, HCPs, healthcare system leaders and decision makers. Authors acknowledge the significant input of J. Grimshaw and W. Levinson, Canada. Key messages • Deprescription of benzodiazepine and sedative hypnotics, especially in older adults, is a priority due to their side effects, particularly in this age group. • The European project BE-SAFE aspires to create easy-to-use guidelines to this aim, improving thus patient safety and healthcare.

Co-producing research on universal health system reform in the context of COVID-19

Abstract Issue How to co-produce and embed research into universal health system reform implementation in the context of COVID-19. In many respects the pandemic revolutionised the use of data and research, with near real-time data informing key health policy and system decisions. This was evident in the production of publicly available data sets tracking COVID-19 infection as well as health system dashboard tracking activity in real-time and influencing day-to-day decisions made. How can this use of data and research evidence become the norm for all health system reform and policy decisions? Results The Foundations’ research project is a partnership project in place since Autumn 2019. Initially focused on producing evidence to inform the design and implementation of new regional areas with the Department of Health Sláintecare Reform Office and the Irish national Health Service Executive as partners. When COVID-19 occurred all work on the regions was paused the research pivoted to harness the learnings form the COVID-19 response to inform universal health system reform. The partnership applied research nature of the programme allowed research to be coproduced and co-designed with health system leaders, meant the researchers understood if and when it was possible to engage with partners and how to feed result into the health system at the earliest opportunity. Lessons Trust and pre-existing working relationships with partners allowed the research to pivot and to continue during the pandemic. The applied partnership nature of the research meant that at times the health system was very engaged in the research and at other times (eg during COVID waves and surges or the cyber-attack) there was limited engagement. The co-production nature of the research allowed a dynamic, ongoing, two-way learning between the health system and the research team. It is extremely difficult to measure impact of research on health system and reform decisions.

Medical silos, social identity, and duty of care: A call for health leaders to improve transitions of care.

This article explores the concept of medical silos, particularly within hospital systems, and examines their deeper roots in social identity and the fiduciary duty of care of healthcare providers. While traditional perspectives focus on informational and communication barriers, this analysis highlights how professional identity and moral obligations contribute to the persistence of silos. Social identity theory reveals that strong in-group affiliations, formed during medical training and specialization, fosters collaboration within groups but also create divisions between them. Similarly, the fiduciary duty of care, central to ethical medical practice, may inadvertently reinforce silo boundaries in resource-limited environments. By emphasizing the role of centralized leadership, the article proposes that health system managers and leaders, with the broadest possible duty of care, must take action to dismantle these barriers. Recommendations include re-evaluating policies for patient transitions and fostering integrated care pathways to improve overall system flow, rather than simply balancing the agendas of stakeholders within their silos.

Engaging primary care patients at risk for suicide in mental health treatment: user insights to inform implementation strategy design

BackgroundGiven that the majority of suicide decedents visit primary care in the year preceding death, primary care has been identified as a key setting in which to engage patients at risk for suicide in mental health services. The objective of this research was to identify barriers and facilitators to engagement in mental health services among primary care patients at risk for suicide to inform the development of strategies to increase engagement.MethodsSeventy-four semi-structured qualitative interviews were conducted with primary care patients (n = 20), primary care (n = 18) and behavioral health (n = 12) clinicians, mental health intake coordinators (n = 4), and health system and clinic leaders (n = 20). Patients who had been referred for mental health services from primary care and reported an elevated score (≥ 1) on item 9 on the Patient Health Questionnaire at the time of referral were eligible to participate. Eligible clinicians and leaders were employed in a primary care or behavioral health setting in a single large health system with an integrated mental health program. Interviews typically lasted 30–60 min, were completed over video conference or phone, and were coded by members of the research team using a rapid qualitative analysis procedure.ResultsParticipants were primarily female (64.9%), white (70.3%) and non-Hispanic/Latine (91.9%). The most identified barriers to mental health care engagement were waitlists, capacity limits, insurance, patient characteristics, communication, collaboration, and/or difficulties surrounding travel. The most commonly cited facilitators of engagement included telehealth, integrated care models, reminders, case management support, psychoeducation, motivational enhancement, and scheduling flexibility. Concrete suggestions for improving engagement in mental health services included increasing communication between providers, streamlining referral and intake processes, providing reminders and follow ups, and advocacy for increased reimbursement for suicide risk assessment.ConclusionsResults underscore the myriad barriers patients at risk for suicide encounter when attempting to engage in mental health care in a primary care setting. Facilitators of engagement and suggestions for improving connections to care were also identified, which can inform the design of implementation strategies to improve engagement in mental health services among primary care patients at risk for suicide.Trial registrationClinicalTrials.gov Identifier: NCT05021224 (Registered August 19, 2021).

The number of patient scheduled hours resulting in a 40-hour work week by physician specialty and setting: a cross-sectional study using electronic health record event log data.

To quantify how many patient scheduled hours would result in a 40-h work week (PSH40) for ambulatory physicians and to determine how PSH40 varies by specialty and practice type. We calculated PSH40 for 186188 ambulatory physicians across 395 organizations from November 2021 through April 2022 stratified by specialty. Median PSH40 for the sample was 33.2 h (IQR: 28.7-36.5). PSH40 was lowest in infectious disease (26.2, IQR: 21.6-31.1), geriatrics (27.2, IQR: 21.5-32.0) and hematology (28.6, IQR: 23.6-32.6) and highest in plastic surgery (35.7, IQR: 32.8-37.7), pain medicine (35.8, IQR: 32.6-37.9) and sports medicine (36.0, IQR: 33.3-38.1). Health system leaders and physicians will benefit from data driven and transparent discussions about work hour expectations. The PSH40 measure can also be used to quantify the impact of variations in the clinical care environment on the in-person ambulatory patient care time available to physicians. PSH40 is a novel measure that can be generated from vendor-derived metrics and used by operational leaders to inform work expectations. It can also support research into the impact of changes in the care environment on physicians' workload and capacity.

Investigating Leadership: Reflections on the methodological choices used to research how allied health clinicians are enabled to step into health systems leadership roles

This article examines the methodological choices made for a research study into Health Systems Leadership. Reflections on key learnings are provided as a way of offering insight for researchers navigating these decisions for the first time. Embarking on qualitative research to effect change is purposeful but challenging; choosing the most appropriate methodology and methods can often be confounding and stressful for new researchers. This article explores the decision to use Interpretive Descriptive methodology with an Appreciative Inquiry lens and makes visible decision junctures in the development of this research. Literature provides a wealth of expert guidance and excellent insights into research methodology and methods. However, very little expounds on the learnings of those who have gone before and what their insights and learnings may be. Research into allied health clinicians and their journey into health systems leadership roles provides an opportunity to reflect on an applied research journey.

A new patient navigation model of care to support older adults in transitions of care: Key considerations for implementation for policy-makers and health system leaders.

A Patient Navigation (PN) model of care was introduced in a large metropolitan hospital in Ontario (Canada) to support transitions in care for older adults in 2019. The patient navigator is a community social worker or "community transitional lead" embedded in the hospital's in care teams to assist with discharge planning and provide follow-up care to older adults, their families, and/or care partners for up to 90 days. Initially, the PN program supported acute care patients and has since expanded in the Emergency Department and Reactivation Care Centre. In this cohort retrospective observational study, we described the new PN model of care by analyzing the clinical notes collected by the patient navigator. This article provides preliminary insights for health leaders who are interested in implementing this novel PN model to improve transitions of care in a hospital setting. Funding was provided by the SLAIGHT Family Foundation.

The Leaders in Informatics, Quality, and Systems (LInQS) Fellowship.

Leaders in Informatics, Quality, and Systems (LInQS) is a non-ACGME (Accreditation Council for Graduate Medical Education)-accredited 2-year training program developed to enhance training in the fields of health care delivery, quality improvement (QI), clinical informatics, and leadership. This single-institution 2-year longitudinal training program grounded in QI and informed by leadership and clinical informatics includes didactics, coaching, and mentorship, all centered around individualized QI projects. The program has been available to sub-specialty fellows, advanced practice providers, and physicians. From 2019 to 2023, 32 fellows have been accepted into the program with 13 graduates and 16 currently enrolled. Fellows have been predominately female, physicians, and from multiple specialties but predominantly hospital medicine. Fellows' evaluations of the fellowship are highly positive, rating the didactics and mentorship aspects of the curriculum most favorably. Most fellows' projects utilized informatics solutions including clinical decision support tools to increase quality of care, improve patient outcomes, and reduce costs of care resulting in manuscript publications, national presentations, and a national specialty society award. Since matriculation, 50% of fellows received certification as Epic Physician Builders and 34% received leadership positions in clinical informatics, quality, and education. Our experience supports the need to provide health care providers more expansive training in the areas of QI, clinical informatics, and leadership for improving health care delivery. Additional in-depth knowledge and experience in these fields may produce and benefit leaders in these fields.

Complex Systems and Sustainable Leadership: Enhancing Resilience and Sustainability of Community-Based Social Enterprises in Soweto, South Africa

In urban South Africa, community-based social enterprises (CBSEs) face challenges at the intersection of financial and environmental sustainability and social purpose. These enterprises address social exclusion and community development within complex institutional environments. Despite increasing governmental support, CBSEs struggle with historical inequalities, resource limitations, high poverty levels, inadequate infrastructure, and complex social dynamics. These challenges contribute to a high failure rate among SMMEs, including CBSEs, which represent approximately 71% of community-level businesses. This study examines how complex system dynamics in marginalized South African suburbs impact the sustainable leadership and resilience of CBSEs. Utilizing a qualitative approach, the study conducted 15 in-depth semi-structured interviews with CBSE leaders. The findings revealed that effective leadership in CBSEs requires extraordinary abilities to traverse complexity, adapt to changes, and engage in dynamic organizational change. The key themes identified included adaptive and flexible leadership, interdependencies and network collaboration, community engagement and co-creation, continuous learning and feedback loops, policy influence and response, and resource utilization and constraints. By applying complex systems leadership theory (CSLT) and sustainable leadership principles, the research offers insights into the mechanisms enabling CBSEs to thrive in challenging environments. These findings contribute to Social Enterprise Management and Leadership Studies, providing practical implications for policymakers and practitioners to support CBSE development and sustainability in marginalized urban communities.