Health Systems Science for Physicians-in-Training

Being indeed Forum I'm going to turn things over to our uh D Lerman for introductions of 513 and clearly Steve thank you Dr wicker it is truly a joy to introduce our two speakers for today's Dean's Forum the full name of Dean's forum is Dean's form on hot topics and challenges in medical education perfect for the topic of today so I'll I will try to do justice to these two wonderful Scholars who are joining us today Dr Anna Chang is Professor of medicine at the UCSF division of geriatrics Department of Medicine she's an educator Mentor clinician and leader nuclear scientist and musician no I'm just kidding this last tour I made those up unless they're true maybe they're true she received her MD degree at St Louis University completed The Residency program in internal medicine at UC Davis and a fellowship in geriatric medicine at UC San Francisco where she also completed the UCSF teaching Scholars Program and medical education research Fellowship Dr Chang is board certified in geriatric medicine and hospice and palliative medicine he's associate chief for education and the division of geriatrics and director of the tides well in American geriatric Society National emerging leaders in aging program she served as the gold-headed cane endowed education share ask her all about that where the name comes from in Internal Medicine at UCSF and as a member of the national board of medical examiners although Dr Chang and I did not exactly overlap when I was at UCSF she is someone whose career I have been following from afar one of her most important roles is to direct the UCSF School of medicine's bridges curriculum clinical Microsystems clerkship the clerkship is one of the most Innovative aspects of the health system science curriculum at UCSF is a longitudinal integrated experience for first and second year students in which they learn clinical skills as well as skills for understanding and improving clinical Microsystems with expert preceptors so welcome Dr Chang Dr Edgar Pierre luisi is a professor of clinical medicine at UCSF he is medical director of the acute care for elders unit at the Zuckerberg San Francisco General Hospital he has cared for vulnerable populations his entire career and is committed to healthcare quality improvement he merged these interests as the founding medical director of the acute care for elders unit and since opening in February 2007 and expanding two years later the unit now cares for over a thousand patients a year which is tremendous Dr Pierre luisi received his MD degree from Harvard Medical School after completing his training in the internal medicine at UCSF and at the Veterans Affairs where he did a national quality Scholars Fellowship he worked for the county of San Mateo our our former home for 14 years as a staff physician medical director of the North County Health Center and a VP for quality improvement he joined the faculty UCSF division of geriatrics in 2006 and San Francisco General's division Hospital medicine 2008 and of course works with Dr Chang and this wonderful initiative at UCSF with the bridges curriculum welcome to Dr Pierre luisi so to both of you I'm just so glad that we had the opportunity to meet a few weeks ago or months ago was it in advance of your visit and for me to reconnect with an institution that helped me develop in the first 14 years of my career in academic medicine I want to thank you both for being here with us in person for meeting with our curriculum leaders and with our teach health system science cohort and for the sunrise Dean's Forum this morning which is very early your time so please everyone please join me for in a warm election day welcome for Dr Shang and Kurt luisi Dean lehmer thank you so much for this invitation the hospitality the warmth the generosity that we've experienced from your team here from The Faculty we've met has this been really really terrific we've learned so much this is such a beautiful part of the country so I want to thank you again for this invitation it's been really special um so we're going to talk today about health system science training for physicians in training a roadmap for today is to State a shared vision for incorporating health system science as a third pillar in medical education Anna will then discuss the current literature pertinent to our approach to integrating health system science in medical education and then we'll describe some of our program outcomes and success as some of success factors that we think were important in integrating Learners and clinicians and learning Health Systems I think I can take this off excuse me okay all right so we're going to talk about the rationale um so for many of you this will you you've heard this story before but I still think it's important to articulate it and and to place it in the context of about 10 or 15 years ago where leaders like Jed and Catherine Lucy and others were the first to pose the question that we're going to get to the problem as they saw it at the time is that we have a problem in the U.S health care System despite being the costliest in the world quality safety disparity patient provider experiences were less than um we're lower than expected and here you see some key Publications this was in 1999 to Aries human which highlighted the problem we have in American medicine with regards to patient patient safety later we saw crossing the quality Chasm which highlighted the problems we had in quality in this country and then the unequal treatment which highlighted the problems we have in disparities I'm going to go through a few data points just to make these points uh uh clear before I do I I will say this I could talk about a ton of data generated from the late 1960s that John wenberg uh showed us about variations in healthcare which raised questions about not only Healthcare resource utilization but quality and how it varied from region to region without any clear uh underlying rationale for why that is the case later there's a lot of work from the Rand Corporation Bob Brook and others uh Elizabeth McGlynn show that in fact when you just look at quality of care in the United States whether it's Primary Care in a hospital the results were not what we had hoped for that data I think is important and it helped I think generate some of the discussions that people like Catherine Lucy and others were having but I'm going to focus on one a paper only because what it did is it takes it takes the U.S and puts it in the context of the rest of the world in terms of quality as well as cost and so we're gonna we're gonna we're gonna move there this is the paper that Ashish Shah published in 2018 and he took oecd data that looks uh that has uh results from uh countries all over the world in particular developed countries and you can and ask about uh outcomes related to Patient Care and compare them to each other and so here you see different uh countries Netherlands Australia France Germany and here's the United States and what we're going to do is compare them to each other and I'm going to do this for a variety of domains so the first is on access and the ability to get a same or next day appointment and here have to respond to the United States we're able to get uh same day or next day appointments compared to other countries we were sort of in the middle of the pack uh if you look at uh clinical outcomes here this is 30-day stroke mortality per thousand patients ignore this thing up here because these I'll go over where they rank but if you look at 30-day stroke mortality per thousand patients the US is doing pretty well it's at 4.2 compared to say Canada or Sweden down around 10. if you look at 30-day mortality per thousand patients within acute MI again the you the U.S is doing very well so the nice thing about this paper is that instead of you know highlighting areas where the United States is doing poorly they had a whole range of metrics and you can see there are pockets of excellence in the United States in terms of healthcare here now this is in terms of clinical outcomes for more stroke mortality in acute MI if you look at avoidable hospitalizations I can avoid this part here here these are the higher the number the worst it is so diabetes hospitalizations as a ratio of people with diabetes us is kind of on the high end of things and it's the highest in terms of asthma hospitalizations as a ratio of people with asthma the idea here is that we're having trouble in the primary care setting preventing hospitalizations I'm just going to spend a little bit of time here you all are familiar with this data in terms of life expectancy whether a life expectancy the total population at Birth or health health adjusted life expectancy the U.S is the worst among these uh among these countries and in addition we have problems with uh Healthcare disparity so since 2003 the agency for healthcare quality and research has produced The National Health Care Quality report uh but starting in 2014 they've merged the health care disparities Report with the national Healthcare quality report and I'm giving I'm going to show you data for 2014 and 2016. just going to focused over here on black population versus white uh population and what they do is they have a a whole battery of quality measures in this case um measures in this case there are uh well we'll go through each of these but it's about 150 or so quality measures or more and what they do and these include things like vaccination rates control of hypertension control of diabetes getting your colonoscopies and mammograms and so on and if you look at blacks versus whites here in 74 of the measures it's 74 of the measures the black patients were uh worse off in terms of these quality measures than whites about in 83 of the measures they were about the same in 19 uh they they were better and while this number has gotten smaller over the years it just points out where we started which was at a pretty bad place because this is still um to my mind unconscionable so um this is a problem again in addition to the Quality metrics we saw embedded in all that we have also have a huge problem with disparities in healthcare in health and Healthcare um no surprise when you ask patients um how are we doing as far as with our system our Health Care system is working well you see that the United States is almost at the very um bottom here um compared to the countries where where we do have where we do have data there's another question that went right right below this I didn't show this here but the question was should we blow up the system and redesign it and of course people from the United States that we were the highest ranking country in answer to that question now I now uh you might say well you get what you pay for and so the question is what what is what are we spending on health care and if we're spending a lot less than other countries you might say okay this is this is about what what you'd expect but you all know that of course we're not this is a listed uh a chart of developed countries and their health care spending per capita and here we're up around 12 000 uh twelve and a half thousand for the United States the next the nearest country down there is Germany and that's at around ten thousand and so we're spending way more than uh other countries here and as a percentage of GDP it's actually even worse so we spent about 20 percent of Health Care in 2020 about 20 was spent uh on of our GDP was spent on Health Care compared to Germany the next country which is about 13 percent so uh we're spending a lot and we're not getting as much as we uh probably ought to in return which led to which I I which reminds me of this quote that um as soon as I saw this this is stuck with me I've used this in a lot of talks when I've talked about rationale for health system science I'm just going to read it if we do nothing to slow these skyrocketing costs and at this point you know if you look at GDP spending uh Healthcare as a proportion of GDP from about 2010 to about 2017 it was about the same it was about 17 getting up to 18. early when this quote was done it had been climbing from 13 14 15 so if you do nothing to slow these skyrocketing costs we'll eventually be spending more on Medicare and Medicaid than every other government program combined every other government program combined and then the conclusion being put simply our health care problem is our deficit problem nothing else even comes close this is from Barack Obama in 2009. what does this have to do with medical education so this is the reframe that leaders like Chad and Catherine Lucy and others asked because up until their um Innovation their Innovative thinking about this nobody was asking this question they just weren't uh but they asked the question and then developed a body of work some of these papers are listed here but a body of work to develop a medical a consensus among medical Educators over the last 10 or 15 years that in fact it has a lot to do with medical education um and the question they asked that was novel was well we've seen what happens when the Health Care system when medical education does not address these issues that is when we don't prepare medical students to become physician leaders who care about improving the systems of the systems that they work in who care about value when we don't do that we get the results we get so it sort of reminds us of the Don Berwick phrase that every system is perfectly designed to get the results it gets and we were getting those results and they were not to uh they were not satisfactory so this body of research helped to make the case that in fact to the degree that are not addressing this is contributing to the problem we have a responsibility to to attend to that yeah and your Dean is one of those leaders who sees this uh when we spoke about this earlier his quote which I thought was terrific we want to graduate leaders who are not running away from the fire and I think the data that I showed is I think you could describe it as a fire uh but running towards it with a water hose our Learners will become system citizens who improve health and health care that's that's the goal so the hypothesis then to summarize is that by incorporating health system science into medical education a medical medical education can be a part of the solution for complex Healthcare delivery problems and improve all the things that we talked about before disparities address increasing complexity uh with social determinants of Health improve quality of care Health Care value and interprofessional teamwork as a stated goal of this education I bring that up in regard to Patient complexity it's clear when you look at care models that address uh for example the medi-medi population they are team based by as a rule you cannot achieve the goals you want to have individually they have done as a team and Physicians need to be part of the part of those teams and in addition physician career satisfaction we don't really we're not going to talk about this too much we can talk about it anecdotally maybe in the question and answer but um this is this is an important this is an important issue when I talk to healthcare leaders in in the Bay Area this is close to number one on their list right now of uh in their concerns how do I prevent physician burnout so I'm going to stop there and Anna will talk about the underlying theoretical framework that helped to drive what it is we did at UCSF I'll just do a quick check on sound it sounds like you can carry how much I will start by echoing Edgar and thanking Dean Biermann it's been an incredible time here you have wonderful people and we've really learned a lot and benefited a lot from this trip so thank you all for your generosity this next section means just to give one example it isn't the only way to do things it is the way that we chose to start trying to make a difference and we're here to learn from you in all the ways that you're also already making a difference in our objectives this next section we will go over some of the current literature that underlie the way we designed our curriculum this was our million dollar question when we started which is how do physicians in training and these are our students standing by with San Francisco VA how do they arrive at the understanding that health system science is a part of their professional identity many of us went through Medical Education Without this being a part of our training we came in as laypeople and exited as Physicians and selling magic happened in the middle and we don't really exactly know what happened we thought that there must be a better way to think about how you might design a program in educational program so that it's a bit more intentional than Let's cross our fingers so in other words what we asked was the question how do you get people to the point where they think act and feel like position oops excuse me so our Approach at UCSF is we thought we designed the learning environment that allowed for communities of practice to shape Learners professional identities that we might be able to move the needle a little bit closer so in other words our approach is based on these three concepts from the medical education literature one is the learning environment the second is community of communities of practice and the third is professional identity formation and we'll go through them one at a time this paper is lovely it describes the learning environment it with a conceptual framework that helps us figure out the areas that we need to attend to either when we're designing a new program or problem solving something that isn't going well in an existing program so I'll just go through some of these from the top left around and these will all make sense to us as we hear them the first is the personal domain obviously the learning environment is around the learner the learner's identity formation depends on everything else here and we are saying that it matters how we shape their personal growth their goals their engagement the emerging autonomy how do we help them be resilient and be well in the process thank you so much and then going from the personal out a bit further we can see that there's a social component to the learning environment the people who surround our Learners that for us would be other Learners physician Educators interprofessional clinicians than others in the area so we believe and the literature shows that learning happens in scaffolded relationships with others learning happens when you become a member of a community and that these interactions when you're teaching and learning and providing patient care are what teaches you what it's like to enter this profession going more broadly into the organization all of us practice and work and learn and teach within organizations medical education and also in healthcare and so what we said was nothing redesigned will be rewards from the organizations within which we exist so the organizational rules practices culture policies are essentially the water that we swim in that we want our Learners to be there as well and then finally physical and virtual spaces when we started thinking about a new program I don't think we realized we have a lot of lesson learned but I don't think we realize how important it is to have the Learners be physically virtually there because what you what happens when you are situated there is you're a part of the interactions that happen around you even if they are not directing teaching at you you're learning by being in the environment so these are the things that will be designed for us and regardless thank you evidence perfect I am really intrigued by this concept that I wanted to bring at you this idea that the learning environment that we design can facilitate transformative learning transformative learning is an outcome of medical education that we want to have we want them to come in and go out and visit our people so we know that transformative learning opportunities influence someone's professional identity we want to design learning programs so that there are opportunities for this kind of learning what we know is that they're best facilitated through immersion in the workplace and what happens when you immerse in the workplaces you become faced with real complex and unfamiliar contexts that challenge you these are described as disorienting dilemmas but they challenge your way of thinking and they change the Learners values attitudes movies and behaviors these are all the things that we want to have happen when we put our workers in the workplace we'll connect this to the second concept from the literature that's important to us when we built our program and that's communities of practice just for a definition this is all going to make sense to us a community of practice is a social network that shares overlapping knowledge beliefs values history and experiences on a shared practice which in our case is the practice of Medicine what we know happens when you put people in communities of practice is that they increase from really everyone in the community Learners and Educators alike a sense of collective identity and shared purpose everyone gains Knowledge and Skills people are more satisfied and they're more productive this next concept connects communities of practice to expertise I'm going to read this quote because this we believe to be true that expertise is not simply a property that passes from teacher to learner but a dynamic commodity that resides within communities of practice so learning according to this theory is a process of absorbing and being absorbed into the culture of such community so this is I think to say that we saw our jobs not as just transmitting Knowledge and Skills or healthy Learners achieve confidence but we're helping them Embrace a different professional identity that includes health system science so the next few slides talk a little bit about what we did again is just one example with one learner level one at one institution but we learned a lot in doing this and we wanted to share this with you for discussion in 2012 our new by Steam for Education Catherine Lucy came in with a vision to say that we are going to overhaul our educational programs and train Physicians to be effective in the 21st century and we did a roughly three four-year design process and launched the clinical Microsystems clerkship in 2016. this is the required longitudinal clinical skills course that integrates clinical skills and health system science for students from the day they enter medical school until the day they go to clerkships our design principle here was that we were not going to do anything just in the education setting that made no sense in the clinical setting if we want to train Physicians to enter the clinical setting effectively we're going to start training them there so important to our design was a strong partnership between medical education and our health systems obviously that existed before we started often in gme a little bit in the clerkships not so much in early medical student education we went to our rehabilitated Health Systems academic safety net County and also RDA and said how about embracing 150 first-year medical students there was a little bit of skepticism were very convincing this happened so what we have are a number of learning communities that happen across a whole lot of different clinical settings that include medical students faculty clinicians everyone looking at the health systems True North that's the picture that's on the right so that we align everything that we do with what's important to our house so in order to do that we had to open up space in the curriculum so we opened up one day per instructional week being the pre-clerkship years so that roughly half of the day is their own into clinical skills training and roughly half of the day is devoted to Health Systems after we opened up space in the curriculum we hired faculty we had approximately 55 Educators engaged in this process from all different clinical sites in all different departments we brought them together to do fairly intense and sustained faculty development so that they would have a shared set of Knowledge and Skills they would have and understanding of our new curriculum so they could become ambassadors to our students we have the same approach to Learners when it comes to problem solving and faculty who are clinicians at a particular Health System also share that context the culture of that health system and also the way that they interact with the interprofessional teams so what happens over time is that the faculty have these um sets of skills Knowledge and Skills that allow them to teach flexibly over time because we're a longitudinal curriculum and this also helps them individualize to each student then we added the students into the learning communities again the Educators our physicians and inter-professional clinicians what we learned is that the students and faculty both benefit from being in the community The Faculty learned from being in the community and our students as well most of our Educators report that Health Systems learning happened regardless of what happened in the student's actual project and so each student faculty group became engaged in a Health Systems Improvement project aligned with a health system priorities and a project goes on for the entire year first year and second year and sometimes they go beautifully and sometimes they're unanticipated barriers regardless the learning outcomes are the same so this is just to say that as we designed something new we thought we've got to figure out if it works and this is how we were going to figure out at least at a local level if it works we use the Kirkpatrick model of evaluation with the four levels and wherever you see in subsequent slides a picture of this pyramid it's a slide that shows some of our outcomes for example our first Kirkpatrick level one outcome the first thing that we asked was first inside of your students do you like what we're doing and um on a scale of one to five our first our early students even before moving on realized that they were experiencing a course that was of high quality and that was of value to them in their development as a physician the second slide has a lot of things on it but this is just to say that we assess Knowledge and Skills which sounds standardized assessments so for clinical skills we had standardized patient assessments for interprofessional collaboration we had clinicians interact with our students years being back on communication and collaborative skills we assess knowledge with Health Systems improvement with the QI cat which is a validated tool that we revised and then also for skills the students submitted based on the lean A3 format that our health systems were using projects progress updates throughout the course of the pre-collection years that then we looked at and assess and gave feedback the summary here is they did fine what we thought what we worried about was when you change something something set up all apart they probably didn't and things did okay so we're continuing to cross our fingers and hope that we're moving in the right direction so a recap of where we've been we've discussed the learning environment communities and practice as two out of the committee Concepts we use and the final concept is professional identity formation professional identity formation is defined as the process through which Learners are transformed from members of the lay public into skilled professionals what we know from the literature is that the most powerful factors having an impact include role models and mentors and experiential learning these are some of the things we intentionally build into our programs and our hope is that this represents progression from legitimate political participation when they come in as an opposite to full participation in medicine's community of practice when they leave us as Physicians so can it work this brings us back to Dean lehrman's vision and also a challenge that we share can we design educational programs to graduate systems that are those who improve health and health care or in other words can we train Physicians to have health system signs as a part of their professional identity we think yes and we'd love to hear your thoughts so the next section in the Edgar will come back and share with you some of our outcomes and also our success factors thank you all right so we're gonna describe again as Anna was saying uh some program outcomes and and some uh some factors that we think were important in the success of integrating Learners and clinicians in learning health and learning Health Systems I'm going to start by just summarizing what we did sort of at a high level um over the last six years we've had almost 290 Improvement projects they are in all clinical departments um we have surgery anesthesia Radiology you see there but including Dermatology Interventional Radiology they took place in clinics in the hospital in the or in the pacu wherever clinical activity is happening we have projects that were representative for their for that area we worked with all its professional clinicians I have listed their psychology social Pharmacy for sure nursing Social Work physical therapists occupational therapists all of the internet professionals we work with have participated in these in these student projects and they were at all the Healthcare Systems as well our academic County and VA and I'm gonna and and we'll go over some of these projects but they really did affect uh disparities quality safety value and patient experience here's just a listing of some I'm just going to highlight two or three of these uh because I think they um they they have raised important principles the very first one is reducing disparities in hypertension control for black patients is it at the University Primary Care Clinic where they showed a disparity in control of hypertension for black patients the students got involved they did a deep dive uh um mostly interviewing patients themselves about their lives some of the issues that were surrounding their uh taking of their medicines and so on perceptions about health care the trust that they have in the Health Care system and through their conversations and then a plan to intervene they were able to increase percentage of patients with at Gold blood pressures by 38 percent so we we're very excited about that one of the things we learned in general we talked about this earlier with Jed is that students were very motivated to work in the area of healthcare disparities so that's an area where students are going to be self-motivated to make change um the other one improving safety of opiate use after minimally invasive surgery this was in a laparoscopic gynecologic oncology surgery uh the unit the the university as a whole identified um opiate prescribing as a problem and we have had probably eight or nine projects at least in the outpatient setting in the inpatient setting in this setting in other surgical settings focused on reducing opiate use many of those have been successful I just wanted to talk about this one here again this is a group of students who then interviewed providers talked about their practice pattern interviewed patients and their expectations around opiate prescribing uh and then talk with our folks in I.T as well made some changes there and were able to decrease prescriptions for discharge opiates by 30 percent there's a couple of things about this project that's really nice one it does align with a higher organizational goal two um they hardwire these changes in working with uh by making these changes part of the part of the EHR and three this is a project that's been picked up year after year so some projects that students work do their work for a year and while the when they leave while the group continues to do the work there aren't students involved with that project that happens in this case students were assigned to this project uh probably for four of the last six years and every single year they've made about a 30 reduction in uh in prescribing opiates which again talks to massive over prescribing which was a problem and they've done the good work of making of using balancing measures to make sure that patients pain pain levels were not worsening and they weren't patients pain levels were actually the same with the same level of control before all this prescribing as um as it was after we reduced all this prescribing so I thought that was that's a nice project I'll talk about one other one here obstetrics again are approving safety of vaginal and cesarean obstetric Hemorrhage this is a project with a student's linked with a Statewide collaborative to re to introduce the measurement of quantitative blood loss uh which helps to actually save lives um reduce maternal mortality and we weren't doing it at sfgh and here they were able to go from not doing it to a high rate of uptake in 84 of deliveries and so um this was a case where the students could see the role of physician Advocates at the state level to to make this a Statewide collaborative and then work locally to make change okay when we assessed questions that we thought got to professional identity we uh we were we were encouraged by these results so we asked now graduating ms4s whether they believe that clinical skills and Health Systems knowledge are both important to Patient experience and clinical outcomes and the majority uh said yes this is at a rating of um one to five and the other was a physician needs to have both clinical skills and health systems and also be successful and again we were we were encouraged by by these results that our students left feeling like this is um a physician does need to have this to be uh to be successful here's some quotes that we took from a wonderful paper that looks at the formation of professional identity in medical school these are from UCSF students well the first is at the end of my career I'll be in a position where the system is still not perfect and still has several holes in it but hopefully I'll be I will look back and see patches that I've made along the way that would be something I'd be proud of and the other I like is a very pragmatic perspective understanding the system is definitely important in the same way that if you're a plumber you should have a good understanding of the pipes that are not within the house itself and so looking you want to look in the walls you want to see see what's underneath there we tried to get at this uh question of identity around the work that we were doing in another way and that was to look at whether or not uh students listed this work that they had done in their residency application CD and most did uh whether or not they had disseminated this work in one form or another uh during their time there and about half had disseminated this work and about a third reporting that they reported that they discussed the work that they had done in the CMC um Health Systems Improvement project in their residency statement or interview and I will say in addition we we made this part of their Dean's letter so there's a separate paragraph in the dean's letter that highlights the work they did as part of a team what problem they were working on how much Headway they made towards that problem and some of the things that they learned which we thought was that was important um here's another quote quality improvement there's always a goal when it comes to Patient Care and residency I will likely see how I can use my power and experience to change parts of the system I'm going to take we're going to take a little bit of idea a digression here to talk about how you might do this in in The Residency uh residency setting now I run something called the health systems leadership pathway that's for residents and fellows mostly medicine residents But it includes pediatric residents Family Medicine residents we've had some ENT some anesthesia residents as well and what we do here is to focus on uh Healthcare quality and Improvement and Health Care policy and we alternate one year with one Focus another year with another Focus we focus on development of personal leadership skills and have um and um and then we go deep into a project and so I want to talk a little bit about the projects to see what we're what we're doing at the gme level is exactly the same thing that we that we're doing at the ume level um just as we over the last 10 years we've had about 125 residents and fellows through this pathway many it went out to become Chief residents and Lead Healthcare Innovations and be leaders and startup companies in the Bay Area and to give you some idea of the kind of involvement I also want to talk about one of these projects here the residents were we have clients we see the people we work with as clients and the client this year was the office for population health and accountable care at UCSF who had a question about whether or not they should invest in home-based primary care as part of their ACO activities we identified 10 academic Health medical centers that we're doing this already we learn from them we took their learnings made a set of recommendations to UCSF they including which positions to actually hire into to help them be successful we then the residents then presented their findings to the CEO and the leadership of UCSF hospital and they accepted those recommendations and invested 1.8 million dollars to help expand their home-based primary care which they thought would help them in the end uh have savings uh Financial savings so this was a case where the residents worked directly with the client that the client has a real world problem that needs to get solved in the next 9 to 12 months and then the residents helped to make help that client think about that problem and then uh and then the client can make their own decisions about what they're going to do and we've done this in other areas as well so what are some of the success factors I'm going to first give some success factors that link to this idea of professional identity and gets back to the question that Anna post earlier about whether involving first-year medical students in this can affect professional identity we think that the data we have is supportive of that notion and we think some of the factors that um that are that are underlying that is one to be explicit about uh including health system science competency as the as a professional as a core competency for for Physicians two is to embrace communities of practice the idea here is that is is that when medical students are embedded in people who are actually doing the work they will see that this um that this really is part part of their day-to-day work it's part of their uh it's part of their identity we felt that if you if you made up experiences for them that just wouldn't be the same and they would see through anything that really truly wasn't authentic so we tried to create these authentic roles both for the students and and the work that they were embedded in the authenticity relates to this engaging Learners the idea here is that the students had to have a real role on the team the team relied on them they counted on them to do work if they didn't the team suffered they saw that and it mattered so we wanted to have them feel like they were contributing in a real way we had to provide a faculty development and as I said earlier you can't provide enough faculty development you have to uh give as much as your faculty are asking for and then there are going to be domains that they will discover later on that are important that you want to think about beforehand and try to address if you can I think that that's important and the last is assessing educational outcomes we try to do that wherever we could um funding was limited for this but we did we did that to the best we could and and you've seen some of the outcomes there with regards to the Health Systems in medical education there are a few things that I think also matter one is integrating learning with um it's really learning about patients and systems so Anna pointed out that we did this all in the same day students got the message that I'm learning how to be a doctor for individuals and I'm learning how to be a doctor for health systems and that was that was um that was explicit uh we invited Learners to join efforts aligned with health system priorities which again Anna pointed out on beginning the link to the Mission Vision Values of the organization really did matter um so we engaged stakeholders including Health Systems leaders and we did this early on um to let them know that we really did want to have our students uh helping them succeed so we wanted to find out what were their pain points and how is it that our students can help them help them address those four is really important to show gratitude to clinical teams that engage with Learners in particular those Qi leads who are not getting paid to do this work it's very important to let them know that you respect the work they're doing and to show gratitude and we did that in a variety of ways that we can talk about later if you'd like and the last was to Showcase and celebrate successes so we created a symposium that was high level all the Deans were invited uh the department chairs were all invited the staff that were engaged working alongside with the medical students were all invited to just to share and what we did at those Symposium is we highlighted four projects that we thought were particularly noteworthy we trained the students to give an effective presentation over five minutes for each project and then um and then we celebrated it we celebrated successes this was really really important I think for for a variety of reasons but it it was a place where everybody could come together and feel the win-win of the work that that the students were doing yes so in summary uh we do believe that education can integrate health system science as as a contributor to the solution to these complex Healthcare problems that we talked about in the beginning that Educators can design learning environments and communities of practice for health for workplace learning aligned with the health system needs and that health system science and clinical skills can be incorporated into the professional identity of physicians in training I want to give a huge shout out to the ccsf clinical Microsystems clerkship team as I said earlier I've done a lot of work that's been very gratifying in the area of quality improvement throughout my career I have never worked with a team that is as competent as hard-working as creative as this team which is a testament to Anna because she built this team and so I just wanted to say thank you to that team it's a real pleasure to work with them and so we'll stop here and take questions.