Shifting gears: Creating equity informed leaders for effective learning health systems

Introduction

Leadership plays an integral role in shaping an effective health system. The importance of this role was on full display during the first and subsequent waves of the COVID-19 pandemic. In the early days of the pandemic, various levels of government and health leaders worked to address and mitigate the impact of a not yet understood, fast moving virus. As the pandemic progressed, reports from around the world noted that the virus disproportionately impacted the health and well-being of those from equity-deserving groups. ¹ These groups refer to groups that have and continue to be marginalized in healthcare due to their race, sexual orientation, gender identity, and other categories of difference. Although the virus’ differential impact was not surprising for those who support these groups, for many, it underscored stark, pre-existing inequities. It also prompted stronger calls for health interventions that acknowledge and actively mitigate and potentially prevent these inequities.

The pandemic further highlighted the need for rapidly evolving, equity-informed healthcare. Although definitions of equity abound, here, it is most succinctly defined as the absence of systematic health disparities between groups that experience various ranges of social advantage or disadvantage. These disparities systematically put those who experience disadvantages due to various factors (e.g., race, gender identity, and socio-economic status) at risk for worse health outcomes vs. those who are socially advantaged. ² Despite commitments at multiple levels of government and health systems that “we were all in this together,” when it came to pandemic strategies and supporting healthcare users, disconnects were often seen between many leaders’ actions and these commitments. This slogan was frequently viewed as a call to simply deliver healthcare “equally” or “notionally fairly” rather than delivering care in ways that, for instance, mitigate the effects that come with equity-deserving groups’ social disadvantages. One study that interviewed 35 global and public health experts found equity was not a priority in high income countries like Canada in the first waves of the pandemic. ³ Rather, the focus was on rapid containment of the virus’ spread and combatting overall COVID-19 related mortalities. ³ As rates of COVID-19 infection and hospitalization became disproportionately higher for those from equity-deserving groups, ⁴ some leaders began searching for ways to rapidly convert research into practice to mitigate the inequities sparking these rates.

One response to this search has been the Learning Health System (LHS) approach—a relatively new framework within the Canadian landscape.^5,6 In Canada, the LHS is defined as the amalgamation of a health and research system that is: (1) anchored on patients’, caregivers’, and community needs and perspectives; (2) propelled by real-time data and evidence; (3) supported by relevant decision supports and governance, financial, and delivery arrangements; and (4) fostered by a culture and competencies for quick learning and improvement. ⁵ In particular, the framework places strong emphasis on the need for patients, caregivers, and community to be actively involved in all stages of health system initiatives’ development, implementation, and rapid-cycle evaluation. Their involvement is considered critical to the success and responsiveness of the implementation of initiatives.^7,8

The LHS also depends on leaders to create an environment where collaboration and flexibility are encouraged. Strong, visionary leadership is seen as critical to inspiring others to share the vision of and sustain health systems’ move towards an LHS.^8,9 An effective LHS requires that patients, staff, and external system partners feel emboldened and comfortable to actively participate in learning. ¹⁰ The LHS requires new ways to work with equity-deserving groups. One way is through ensuring all non-Indigenous LHS participants take Indigenous cultural safety training to help foster equitable, forward thinking learning health systems. Leaders must be trained to nurture ethical decision-making in the LHS. ¹⁰ Additionally, leaders create an environment where staff feel empowered to provide constructive feedback that is used to support the frequent enhancement of system processes for continuous improvement. Leaders position their health system to create conceptual business models that propel them towards a learning culture. ⁸

Throughout the pandemic, many health leaders have used the LHS to help them rapidly use research to inform practice to address many pressing COVID-19 healthcare needs. For instance, academics and policy makers from the University of Saskatchewan, Saskatchewan Health Authority, Health Quality Council, and Ministry of Health in Saskatchewan used portions of the LHS framework to develop the COVID-19 Evidence Support Team. ¹¹ The Team aimed to create a rapid review process to support pandemic decision-making, develop an online repository space to share knowledge, and to begin an LHS in the province. A qualitative, formative evaluation of 13 Saskatchewan health system leaders’ experiences who used the Team’s work found that this work supported decision-making, guided health system leaders, hastened scientific evidence reviews and fostered partnerships and knowledge transfer in the health system. The online repository was viewed as a transparent and effective mode of delivering new pandemic evidence reviews. ¹¹ In the United States, one health system used the LHS approach to develop a multidisciplinary COVID-19 therapeutics committee in early 2020 that assessed potential COVID-19 treatments and quickly disseminated data-driven clinical recommendations to all out- and in-patient facilities that had patients with the virus. The committee’s impact was evaluated by time series plotting of the prevalence of in-hospital use of key medications in relation to internal analyses and specific scientific publications and regulatory approvals frequently reviewed by the committee. A temporal review of the 30-day rate of mortality of hospitalized patients with the virus also occurred. Researchers found in-hospital mortality of these patients decreased by an average of 5%, suggesting ongoing learning effects to enhancing patient care. ¹² Although this research and others highlight the potential benefits of implementing LHS on patients’ health and overall outcomes, scarce literature examines the role of health system leaders’ use and/or incorporation of equity in the LHS. This article seeks to begin addressing this gap by first examining how equity can be integrated into LHS activities; and second, discussing leaders’ role in ensuring that equity is contemplated and achieved in rapid learning cycles.

Achieving equity in learning health system activities

Core to the notion of the LHS is the cyclical generation, synthesis, application, and refinement of high-quality evidence into healthcare. ¹³ Key to the LHS concept is the integration of patients, caregivers, and community perspectives on health system evolution and change so that systems are more responsive to their needs, perspectives, and aspirations.^13,14 Recently, equity has been called out as an essential LHS component making explicit the objective of narrowing inequities in both accessing healthcare and in achieving health.^15,16

The LHS envisions that five main types of research evidence are generated, integrated, applied, and refined in iterative learning cycles where equity is a central consideration throughout. ¹⁷

The first evidence type—advanced population-based analytics—refers to advanced descriptive, predictive, or causal analytics that generate actionable and timely insights sourced by the “big data” of contemporary EMR (Electronic Medical Records), administrative data bases, and other data sources. These quantitative insights are supplemented by other qualitative research approaches that gather input and understand individuals’ and populations’ healthcare experiences and contexts. The second evidence type—evidence synthesis and curation—refers to the rapid synthesis and contextualization of existing global evidence to identify the nature, success, or failure of solutions to similar problems tested elsewhere. The third research method and evidence type—patient, caregiver, and provider co-design—is a core component of the LHS and refers to the application of advanced methods to engage key stakeholders (patients, caregivers, practitioners, and community members) in multicomponent solution design. Essential to state-of-the-art co-design methods is the robust engagement and trust building with those directly impacted by healthcare problems. The fourth evidence type is the application of implementation and behavioural science methods to foster systematic and routine design of interventions utilizing methods that enhance health service effectiveness. Finally, the last evidence type refers to realist evaluation methods that assess the efficacy of multicomponent interventions, with the rapid feedback and adaption of the solution as necessary. These LHS evidence streams are acted upon and supported by contextual factors that can hasten (e.g., leadership, funding, and scientific expertise) or slow progress and rapid learning success (e.g., health system capacity priorities, laws, and regulations privacy). ¹⁷ To effectively function, the leadership necessary for the LHS is collaborative in nature and includes health system, research, and community leaders. Without this leadership triad, the LHS engine cannot move system change forward. ⁶

A central challenge for all LHS initiatives is ensuring learning is defined from the perspectives and values of individuals and those from equity-deserving groups. Collaborating with equity-deserving groups requires that leaders acknowledge and work to address a well-founded distrust of health systems ⁶ and move towards achieving active participation and establishing meaningful partnerships with these groups. As many health equity gaps are caused by factors external to the healthcare system, the LHS fosters expanded thinking and new relationships by underscoring the impact of these factors (e.g., employment, housing, education, and income assistance) on health outcomes.

Equity-informed leadership for an effective LHS

Just as the LHS encourages leaders to account for the aforementioned external factors and create sustainable partnerships with patients, caregivers, and communities to inform health system change, so does it necessitate them to use an equity approach to address health issues. Despite this necessity and calls to incorporate health equity into LHS research training, ¹⁸ scarce literature delves into how leaders understand and foster equity in the LHS, the components of equity-informed leadership within the LHS, and how to effectively train leaders to implement an equity-informed LHS in their respective health system. Literature from other realms of healthcare practice and business provide some insight that may help begin addressing these gaps and areas where leaders should grow their skills to help move the LHS forward. For instance, a team of American public health scholars have developed an equity-focused competency framework for leadership development programs. ¹⁹ The framework was sparked by the COVID-19 pandemic that further illuminated pre-existing health disparities experienced by racialized and ethnically diverse peoples. Similar to the LHS engine, this framework consists of several interlocking domains whose effectiveness depends on the functioning of one another. Its four domains are informed by traditional leadership and equity, diversity, and inclusion skills. The personal domain seeks to grow a mindset of self-awareness of leadership style strengths and encourages individual differences to bolster engagement with diversity. The interpersonal domain focuses on growing the skills needed to construct and lead through relationships with diverse individuals. The organizational domain seeks to create a systems orientation to leadership and reviewing and understanding approaches to use evidence to move organizational culture. Lastly, the community and systems domain centres on building skills to engage and collaborate with communities and stakeholders to address present and future structural drivers of health equity. Much like the LHS engine, this leadership framework views equity as a foundational component that must be addressed beside and integrated into leadership competences. ¹⁹

Moving the LHS engine forward with equity-informed leadership

As the LHS framework continues gaining popularity in health systems, more system leaders will have to acquire the skills needed to foster, implement, and sustain LHS approaches. Although literature from other areas of healthcare practice and business offer some insight into ways to develop equity-informed leaders, there are several vital skills leaders will need for a LHS to thrive and be sustainable.

We offer some strategies to help leaders incorporate a more equity-informed approach to the ways they guide their LHS, support staff, and build and maintain patient, caregiver, and community partnerships. Leaders must be explicit that equity is an organizational priority and allocate resources (e.g., researchers and staff) that work towards decreasing health disparities. Leaders must provide sufficient and sustainable funding needed for research priorities that are equity-focused with content and results that can be used across the health system. This funding should come with supports in the form of staffing, data analysis tools, and dedicated time reserved for staff to conduct this work. As noted by the LHS engine framework, numerous individuals, partnerships, and resources are needed for the engine to thrive and operate smoothly. Leaders must be inclusive and foster partnerships and seek out expertise beyond health systems. This expertise includes the lived experiences of patients, communities, and caregivers. Gaining this critical insight requires that leaders put in the work to build deep and trusting relationships with these populations, particularly those from equity-deserving groups. Relationship building also applies to health system data used to inform the LHS and, in turn, healthcare. It is not enough to merely collect and review patient data, an ongoing partnership with patients, caregivers, and communities is vital in order to effectively contextualize and potentially apply analyzed findings to healthcare. Further, leaders must commit to holding themselves and their health systems accountable to the communities they serve. They must be open to taking a supporting role in shaping healthcare resources. This accountability requires that leaders are transparent in how they select and use inequity measures, continuously co-design mitigation solutions, constantly engage with and request feedback from communities about data findings, and commit to act on these findings. This commitment is one step towards rebuilding trust amongst equity-deserving groups, many of which have experienced various forms of discrimination and racism from the very health institutions pledged to heal them. Trust building often occurs over time and can only be achieved through active listening, prioritizing equity-informed action, and engaging in solutions focused health system designs.

Leaders should encourage and support the development of the next generation of LHS leaders. In Canada, the Canadian Institutes of Health Research offers the Health System Impact Program. The program provides doctoral trainees, post-doctoral scholars, and early career researchers in health services, policy research, and related fields the chance to team up with institutions to create embedded research initiatives that respond to some of the most pressing issues facing health systems and support evidence-informed decision-making. This program allows for a bidirectional learning opportunity where up and coming scholars have the chance to impact the system in real time while leaders are exposed to new ideas and approaches to healthcare initiatives. ²⁰

Conclusion

As the LHS evolves, so too does the opportunity for an equity lens to be further embedded into capacity building programs and space made for scholars who can bridge the gap between health systems and communities to help create sustainable health initiatives. A sustainable approach to equity within the LHS requires active and ongoing engagement with patients, caregivers, and communities. In embracing the LHS approach, leaders must foster environments of accountability where learning from staff and the lived experiences of those whose voices are often silenced in health systems is commonplace. Simply put, unless leaders work to embed equity into their accountability frameworks and engagement with patients, caregivers, and communities, leaders will miss the opportunity presented by the intersection of the LHS and equity. Ultimately, equity-informed leaders will not only help keep the LHS engine running but will have real-time impact on the health and well-being of individuals and populations.