Background

As healthcare undergoes significant changes aimed at improving outcomes, both health systems and medical schools must evolve to ensure physicians have the necessary skills to address healthcare challenges (Berwick and Finkelstein 2010; Cooke et al. 2010; Grumbach et al. 2014; Skochelak 2010). Physicians unprepared for practice within health systems will face difficulties in improving health outcomes for individuals or populations. To address the challenge of educating collaborative systems-focused physicians, medical schools are embracing a new three-pillar framework that integrates biomedical and clinical sciences with Health Systems Sciences (HSS), including concepts such as population health, health policy, interprofessional collaboration, and systems thinking (Berwick and Finkelstein 2010; Combes and Arespacochaga 2012; Cooke et al. 2010; Cordasco 2009; Crosson et al. 2011; Gonzalo et al. 2017a; b; Lucey 2013; Skochelak 2010; Skochelak et al. 2016).

To effectively teach HSS, educators need to identify practice-based experiences that augment classroom-based curricula (Gonzalo et al. 2014). Medical schools are experimenting with value-added clinical systems learning roles whereby students contribute to health systems by improving care processes and outcomes while simultaneously learning HSS (Association 2014; Chen et al. 2013; Gonzalo et al. 2014; Lin et al. 2015). These roles are in contrast to current experiential roles that focus on learning doctoring skills from physician faculty within practice settings, which requires time and resources that are sometimes viewed as a liability (Chen et al. 2014; Gonzalo et al. 2014, 2017a; Jones and Korn 1997; Shea et al. 1996). The need to enhance HSS education and develop value-added roles provides an opportunity for medical education to shift from a potential burden to a potentially unrecognized asset (Jones and Korn 1997; Shea et al. 1996; Thibault 2013). Despite potential benefits to students and health systems, little work has explored facilitators or barriers to implementing the kind of value-added clinical systems learning roles that could be widely adopted by medical schools (Lucey 2013). In 2014, we created a large-scale network of sites in which students served in these roles (American Medical Association: Accelerating Change in Medical Education Initiative 2013). Using this network as a laboratory and a Diffusion of Innovations framework, we were interested in identifying practical strategies, key facilitators and barriers to advancing this education agenda.

Diffusion of Innovation is a theory advanced by Rogers to understand how stakeholders in a social system learn about, decide upon, and act on ideas or practices they perceive as new (Rogers 2003; Rohrbach et al. 1993). It is characterized by five stages: (1) knowledge—or planned efforts to make potential participants aware of the new practices, (2) persuasion—or building support for the innovation, (3) decision—or the intention to try the program, (4) implementation—or interventions to assist participants in delivering the new approach as it is aligns with program goals, and, (5) maintenance—or encouragement of participants to continue the innovation. In a prior work, we described early persuasion and decision techniques (stages 2 and 3) found to be beneficial in this innovation; the focus of this current work was on stages 4 and 5 (Gonzalo et al. 2017c). In alignment with Diffusion of Innovation theory, our design specifically targeted three key stakeholder groups in the implementation and maintenance stages: (1) educational leadership, (2) health system site mentors, and, (3) medical students experiencing the program (Murray 1986; Rogers 2003).

Methods

Study setting and design

In 2014, Penn State College of Medicine (PSCOM) implemented a HSS course that included value-added clinical systems learning roles in the form of patient navigation (Gonzalo et al. 2014, 2017b). Patient navigators hold a unique role in modern-day interprofessional healthcare teams as they identify patients’ barriers to care and help patients navigate complex health systems to obtain quality care (Freeman and Rodriguez 2011). The student patient navigator role was designed to provide experiential learning by embedding each student into an interprofessional care team to help address patient needs. In the 2014–2015 academic year, 85 of 150 first-year students were placed across 16 sites, and in the 2015–2016 academic year, 144 of 150 first-year students were placed across 36 sites. Our team’s perspective in this study was that value-added clinical systems learning roles are important for medical student education and health care transformation. Although our prior work in this area informed this project, we employed several strategies to assure a de novo exploration. To address our reflexivity, we used several methods in the participant sampling, data collection, and analysis to limit any potential biases in themes or categories (Mauthner and Doucet 2003). All faculty investigators had 3 years of experience with this program, and were sensitized to possible results identified in the data. For example, investigators identified prior to the start of the study that site capacity to accommodate students and student engagement were likely to emerge as key findings. The study was facilitated by three experienced researchers (J.G., D.W., and B.T.) during all phases, including conceptualization, data collection and analysis, and writing of the manuscript. The study was approved by the Penn State Hershey Institutional Review Board (STUDY00005150/STUDY00005278).

Data sources and collection

To ensure credibility of our data and results, we triangulated data from three sources and across several clinical sites and stakeholder groups: field notes from site observations, 1:1 interviews with site mentors, and focus-group interviews with students who had completed the experience (Shenton 2004). One investigator (D.G.), PSCOM’s Patient Navigation Coordinator, performed observations at clinical sites (n = 32, January–June 2016); four sites were excluded due to scheduling challenges. During visits, the investigator observed student activities, asked pre-determined questions of students and mentors, and recorded detailed field notes (“Representative field site questions and prompts” Appendix section). Four semi-structured, audio-recorded, focus-group interviews were conducted with 4-8 students, and performed by an experienced facilitator (B.T.) following the students’ year as patient navigators (September–October 2016). Students were invited to participate from one of four placement groups: (1) primary care clinics, (2) specialty-based clinics, (3) underserved/free clinics, and (4) transitions programs; a maximum of eight students was allowed to sign up for each group. Questions related to students’ experiences, expectations, types of patients and mentoring at their site, resources needed, barriers, and perceived value to care and education (“Student patient navigator focus-group interview guide” Appendix section). Last, a research assistant experienced with performing telephone interviews conducted 1:1 interviews with mentors who coordinated oversight of student patient navigators (August 2016–January 2017). Questions related to strategies, barriers, and facilitators in implementing and maintaining the program (“Representative site mentor interview questions and guide” Appendix section) (Harting et al. 2009). In addition to qualitative data, we compiled a list of all sites and their status after the 2015–2016 academic year (continued, modified, or withdrawn). All interviews were audio recorded, and a professional transcriptionist transcribed all audio verbatim.

Data analysis

Data from field notes, 1:1 interviews and focus-group transcriptions were integrated into one dataset for the analysis phase. The data were analyzed using thematic analysis to identify categories and themes (Bernard and Ryan 2010; Boyatzis 1998; Braun 2006). Two investigators with experience in qualitative analysis (A.A., D.G.) first independently analyzed one set of field notes looking for phrases or words that recurred frequently to create an initial codebook. Through independent coding and regular adjudication sessions, initial codes were compared for inconsistency and agreement, followed by updating of the codebook. Analysts discussed disagreements, and modified codes as necessary. The unit of analysis was phrases containing one idea (Elo and Kyngas 2008). We used a form of peer debriefing with the individuals who conducted the interviews to help ensure that we were interpreting the meaning of the interviews according to the context that occurred in real time (Mauthner and Doucet 2003). As suggested by qualitative research, we sought to be flexible with emerging data to meaningfully organize results (Miles and Gilbert 2005). In this process, we identified strategies for implementing patient navigator programs, along with barriers and facilitators in accomplishing this goal, all of which were iteratively discussed by the research team. In this process, we developed a Key-Driver diagram of influential areas and strategies to be considered by others in developing and implementing a similar model. The research team discussed the findings and selected quotations (from the transcribed interviews and focus groups only) for inclusion in the results. We used NVivo10 and11 QSR International software to manage the data.

Of the 36 sites implementing the patient navigator program, 32 site observations were completed (mean 4 h per observation; estimated total of 130 h). Four focus-group interviews were completed with 24 students (mean 47 min, range 34–72 min). A total of 29, 1:1 interviews (88% participation rate) with site mentors was performed (mean 28 min, range 21–75 min). A total of 375 pages of double-spaced textual data was analyzed (field notes = 65, mentor interviews = 260, focus-group interviews = 50).

Results

Here we describe characteristics of clinical sites, and core elements, facilitators, barriers, and strategies to improve the implementation and maintenance of a student patient navigator program.

Site characteristics

Of 36 clinical sites implementing the program in 2015–2016, 22 (61%) were affiliated with PSCOM, 10 (28%) were affiliated with a community-based hospital/system, and four (11%) were independent or state-run programs (Table 1). Of 36 clinical sites, 17 (47%) continued the program, eight (22%) significantly modified the program and down- or up-sized the number of students, and 11 (31%) withdrew from the program. Of withdrawing sites, 6 of 11 (55%) were affiliated with a community-based hospital/system, 4 of 11 (36%) were affiliated with PSCOM, and 1 of 11 (9%) was an independent clinic.

Table 1 Clinical sites and programs included in student patient navigator program
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Strategies for implementing a value-added clinical systems learning roles program

Our data identified core elements important to implementing and maintaining a value-added clinical systems learning roles program. Table 2 provides examples, based on our data, of the program in four settings: outpatient primary care clinic, specialty-based clinic, free/under-served clinic, and transitions program. Table 3 provides the necessary student orientation and continuous education, patient characteristics best suited for students, patient selection processes, student activities, and resources students could use within each setting. All sites developed educational methods about the site, scope of practice of interprofessional providers (e.g. care coordinators, social workers), and various resources available to patients (e.g. transportation services, community resources). Types of patients and their characteristics were considered in all sites, with patients most “in need” of navigation being a top priority. Patient selection processes were varied and included quality metric reports of superutilizers, provider referrals, and care coordinators’ awareness of vulnerable patients. Student tasks and activities were also important, including communicating with providers, interacting with patients during visits, making telephone calls for follow up, and conducting home visits. Although common strategies were identified across sites, the degree to which activities were performed by students in sites was variable since each ‘modified’ the program to fit their needs.

Table 2 Examples and descriptions of clinical sites in the student patient navigation program
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Table 3 Strategies and best practices for implementing systems roles in four different clinical sites and programs
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Facilitators and barriers to the program

Our data suggested six themes related to barriers, facilitators, and strategies to improve the implementation and maintenance of value-added clinical systems learning roles. Table 4 includes representative quotations for each of these themes. A total of 746 coding references was applied to the data in the analysis—the number and percentage of the total of coding references are also included below. A Key-Driver Diagram depicts outcomes, drivers, and potential solutions for each theme (Fig. 1), and Table 5 summarizes key features for successful implementation.

Table 4 Representative quotations for each theme relating to facilitators and barriers to implementation and sustaining a student patient navigator program
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Fig. 1
figure 1

Key-Driver diagram of outcomes, priority areas, and potential strategies for implementing value-added clinical systems learning roles for students in medical schools. The figure demonstrates the relationships between the outcomes (proximal and distal), “key driver” factors, and the potential interventions that could potentially influence the key drivers

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Table 5 Top five key features for successful implementation of value-added clinical systems learning roles for medical students
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Educational value (n = 302, 40%)

Early exposure to patient care helped prepare students to recognize barriers impacting patient health, advance students’ problem-solving skills and raise awareness of required time and resources to effectively resolve issues. Many students documented in the electronic health record (EHR), allowing them to further develop informatics and information technology skills. Mentors and students believed these experiences could provide essential skills for future physicians.

Valuable experiences were described as those in which students were integrated into team processes and assigned independent tasks, such as home visits, follow-up telephone calls, identification of community-based resources, and assisting patients in overcoming barriers. While these positive perceptions tended to be facilitators of success and continued site participation, negative perceptions acted as a barrier. Students described experiences where they primarily shadowed providers, completed repetitive tasks, or had limited autonomy or engagement, which limited the perceived educational benefit.

Value added from student work (n = 177, 24%)

At many sites, students and mentors believed the students extended the work of the site and added value to patient care. Participants commented that students provided psycho-social support to patients, “lightened” [mentor] the workload of care teams, and provided a “fresh pair of eyes” [mentor]. They added value by identifying additional community resources, providing education, and addressing patient barriers. Table 3 provides activities performed by students. Mentors often felt invigorated after working with students, but this was not always the case. At sites where mostly shadowing occurred, neither students nor mentors found the program to be useful. Additionally, there was often a disconnect between student expectations of what they should be doing, and the work they actually performed. Some students expected to “save the lives of patients,” but their work in educating patients or identification of community-based resources was often perceived as of little value.

Mentor time and site capacity (n = 128, 17%)

Mentor time and site capacity for student work were both facilitators and barriers to success. While students perceived mentors who worked with them as an educational benefit, several mentors believed one of the biggest barriers was that the program could become an “add-on” to daily work. Some mentors spent up to 4 h preparing for sessions, and also spent time during each session on patient selection and discussion of patient profiles with students. Clinical space and resources were also challenges, as mentors often had to locate empty desks or telephones for student use. Other factors, such as implementation of a new EHR, lack of staffing, funding, and structural changes of the location, affected the site’s ability to maintain the program. Several sites withdrew due to anticipated implementation of a new EHR and increased workload expectation for mentors.

Student engagement (n = 60, 8%)

An influential factor in the program’s success was student engagement, which varied significantly across and within sites. Fully-engaged students were able to proactively problem solve and assist patients and recognize the work they were performing as a learning opportunity. While engagement was viewed as a facilitator, modest student engagement was a barrier to success. The reasons for limited engagement were varied. Data indicated some students had difficulty understanding the applicability of the program to their future careers and felt underqualified for the role. Others needed encouragement or prompting to understand how to assist patients to overcome barriers. To improve the degree of engagement, students needed training at the site. Table 3 provides core elements of training that students needed to be successful, along with knowledge of essential resources for their roles. A primary reason several sites withdrew from the program was mentors’ frustration and resultant increased workload when students demonstrated limited engagement or motivation to contribute to patient-centered activities.

Working relationship between school, site, and students (n = 51, 7%)

Logistically, the relationship between the school, sites, and students required ongoing communication, collaboration, and problem-solving for programmatic improvement. In particular, the school and sites increasingly recognized the need for ongoing communication, collaboration, and sharing of ideas across sites related to best practices to ensure most-optimal conditions were created for learning and patient care. Through observation and participants’ comments, many sites encountered challenges that needed to be addressed in the short term to achieve success. The need for a continuous improvement cycle to address and prevent issues was identified as critical. Mentors described monthly check-ins and yearly “retreats” by the school as vital to making improvements and important to building a network between mentors. Students described critical improvements at the school level, such as improving students’ introduction to the program, setting up realistic expectations, and creating resources and guides. As such, program leadership sought student and mentor assistance to improve resources, guides, and student training. The program also relied on student and mentor feedback to continuously improve experiences.

Continuity (n = 28, 4%)

Continuity of navigation for students’ work was an influential factor in the program’s success. Even though students had specific bi-weekly afternoon sessions scheduled for patient navigation, it was not unusual for events such as examinations, holidays, or other class events to disrupt regular participation. This discontinuity was identified as a hindrance to team integration and opportunities to contribute to patients and clinics as a whole. However, several sites noted improved continuity of care when students followed up with patients outside of scheduled days.

Discussion

In this study, we identified facilitators and barriers to implementing and maintaining a program that integrates students into value-added clinical systems learning roles as they learn health systems science (HSS) competencies. After program implementation, 17 of 36 sites continued, 8 sites modified, and 11 withdrew from the program. The majority of sites that withdrew from the program were in other health systems or community-based hospitals rather than affiliated with our Academic Health Center. Using the Diffusion of Innovations lens allowed us to consider the facilitators and barriers that may have led to these results (Rogers 2003). In particular, we identified barriers such as limited student engagement, limited value added to care from student’s perspective, mentor time and site capacity, underdeveloped resources of either the school or site to make continuous improvements, and continuity of experiences for students. Most importantly, we identified five key strategies for other health professional schools to consider when implementing similar programs (see Table 5): integrate students into interprofessional care teams to allow for authentic interaction, ensure students are aware of site functionality and their role within team, provide students the opportunity to add value to the clinical sites rather than observe, provide students opportunities for continuity with patients and providers at each site, and develop a proactive continuous quality improvement process between curriculum, students, and mentors. We believe this study provides a useful window into key factors necessary for medical schools to develop and sustain sites within and, in particular, outside of Academic Health Centers.

As care delivery and medical education undergo significant reform, medical students can learn about and contribute to health systems by participating in activities that add value (Lin et al. 2015). Our study suggests that value-added clinical systems roles have the potential to bridge classroom-based learning of HSS and clinical science with hands-on, patient-centered experiences in the setting of evolving care delivery and medical education reform (Gonzalo et al. 2017b; Lucey 2013). These roles are increasingly being described in the literature, but practical factors to consider during implementation and maintenance have not been well delineated (Curry 2014; Gonzalo et al. 2014, 2017c; Gonzalo 2017; Lin et al. 2015). We believe this study can guide other health professional schools developing similar programs with similar goals. This study defined practical aspects, such as site orientation and continued training for students, along with resources students need to be successful. It also identified patients best suited for student work.

An important finding in this study relates to the influential contribution of student engagement and initiative to sustain such a program. Student engagement has been identified as a rate-limiting factor in educational innovations, particularly during a time when undergraduate medical education programs are rapidly transforming to prepare systems-ready physicians (Gonzalo et al. 2017; Irby 2011; Lucey 2013; Skochelak 2010). Historically, student characteristics that can predict student engagement and performance have revealed that those who perform better on preclinical science coursework tend to be “narrower in interests, less adaptable, less articulate, and less comfortable in personal relationships” (Gough 1978). More recently, recommendations have been made by the Association of American Medical Colleges to shift the principal emphasis for admissions away from undergraduate science preparation to a more holistic approach, including students’ commitment to service, cultural sensitivity, and interpersonal skills (Witzburg and Sondheimer 2013). This historical context may, in part, provide insight into the variable degree of student engagement. Success in the patient navigator role depends on students taking an active role, applying interpersonal communication skills, and committing themselves to the patients and the care team, all in the face of curriculum-based priorities. Going forward, it remains to be seen if these challenges to student engagement can be successfully addressed. This includes attention to system issues, such as high-stakes board examinations that currently de-prioritize HSS competencies. Additionally, future studies should evaluate the consequences, good or bad, of placing students into value-added clinical systems learning roles early in medical school. These roles expose students to challenging systems issues early in their career that they would have previously only encountered in clerkships or residency training.

We propose that educational and clinical value go hand-in-hand, and medical schools and sites must work together to create experiences for students that achieve both goals. Our data suggest that there are strategies for enhancing educational value, including encouraging experiences outside of clinical sites, such as home visits, or ensuring students receive oral/written feedback throughout the program. In return, students must be able to provide value to sites (Gonzalo et al. 2017d). Interventions to foster student value include reframing student roles as “extenders” of clinic work and clinical care needs. To achieve this goal, medical schools need to create meaningful curricular space and priority for students to take advantage of opportunities for continuity with mentors and patients. Schools and sites need to collaborate on partnerships built on shared goals and objectives that can accommodate inevitable disruptions and changes while developing a shared investment in education and patient outcomes. We have identified some of the key drivers that need to inform these relationships.

This study has several limitations. First, services provided within sites were varied, and all sites were geographically located in south-central Pennsylvania, potentially limiting generalizability to other site types and regions. Second, while we purposely conducted focus-group interviews with students in each of four clinical site types, participating students were volunteers, raising the possibility of selection bias. Lastly, data used in this study were from the first 2 years of the program, and longer-term outcomes were not available. However, we believe these findings are an important starting point for understanding how to develop and implement such a program.

In conclusion, our results identified facilitators, barriers, strategies, and best practices for implementing and maintaining value-added clinical systems learning roles. We believe that understanding these elements is critical to sustaining a community-based program such as this. Factors relating to students, including their engagement and perceived educational benefits, and those relating to sites, including the value added to clinical care, acted as either facilitators or barriers depending on context. In addition, mentors identified barriers that affected their ability to provide effective oversight for students, including time, students’ schedules, clinical capacity, and space availability. We believe that value-added clinical systems learning roles will be key to addressing the challenge of educating systems-ready physicians in the 21st-century, and that data from studies like this one will be important for developing and sustaining effective programs.