The triple helix of clinical, research, and education missions in academic health centers: A qualitative study of diverse stakeholder perspectives

Abstract Introduction Academic health centers are poised to improve health through their clinical, education, and research missions. However, these missions often operate in silos. The authors explored stakeholder perspectives at diverse institutions to understand challenges and identify alignment strategies. Methods Authors used an exploratory qualitative design and thematic analysis approach with data obtained from electronic surveys sent to participants at five U.S. academic health centers (2017‐18), with four different types of medical school/health system partnerships. Participants included educators, researchers, system leaders, administrators, clinical providers, resident/fellow physicians, and students. Investigators coded data using constant comparative analysis, met regularly to reconcile uncertainties, and collapsed/combined categories. Results Of 175 participants invited, 113 completed the survey (65%). Three results categories were identified. First, five higher‐order themes emerged related to aligning missions, including (a) shared vision and strategies, (b) alignment of strategy with community needs, (c) tension of economic drivers, (d) coproduction of knowledge, and (e) unifying set of concepts spanning all missions. Second, strategies for each mission were identified, including education (new competencies, instructional methods, recruitment), research (shifting agenda, developing partnerships, operations), and clinical operations (delivery models, focus on patient factors/needs, value‐based care, well‐being). Lastly, strategies for integrating each dyadic mission pair, including research‐education, clinical operations education, and research‐clinical operations, were identified. Conclusions Academic health centers are at a crossroads in regard to identity and alignment across the tripartite missions. The study's results provide pragmatic strategies to advance the tripartite missions and lead necessary change for improved patient health.


| INTRODUCTION
Health systems are striving toward the Quadruple Aim of improving patient experience, advancing population health, controlling costs of care, and securing clinician well-being. 1,2 Achieving these goals will depend on how effectively dynamic and robust principles of system learning and continuous improvement are embedded into processes, structures, and mental models. [3][4][5] Academic health centers (AHCs) bring an added degree of complexity to this challenge, adding core missions of research and education to the aspirational care outcomes framed by the Institute for Healthcare Improvement (IHI). 6 Defined as "a constellation of functions and organizations committed to improving the health of patients and populations through the integration of their roles in research, education, and patient care," AHCs should be well-positioned to take the lead in improving health and transforming systems of care if their missions are integrated and aligned. 6,7 Unfortunately, careful analysis often reveals silos rather than synergy. 8 Mission alignment within an AHC depends on utilizing management, finances, governance, and strategy in the context of a flexible, dynamic work process, and a shared vision. 8,9 Several forces have challenged the viability and cohesion of AHC tripartite missions including new economic models, particularly the costs associated with education and research, decreased governmental support, and changing health policy. [9][10][11][12][13] Clinical care is adapting to a stuttering movement from fee-for-service to value-based care, while attempting to respond to the rapid evolution of bioinformatics, technology, and consumerism. Research programs are challenged to fund promising investigators and important scholarship. Health professions education is challenged to reimagine learning agendas to prepare future clinicians to meet patient and system needs. 14 Academic health centers experience enormous short-term pressures to remain viable while navigating new and evolving healthcare landscapes that often overshadow the long-term goal of aligning missions. Collectively, the tripartite missions are inter-related and require more than independent adaptations to align with evolving needs. 15 System leaders have reported significant variability in the degree to which medical education and clinical and basic science research are shared within AHCs. 9 At the same time, although leaders believe alignment is critical, 75% report not knowing how to implement strategies to achieve this. 8 Limited work has explored the pragmatic translation of alignment into actionable strategies. 9,16 2 | RESEARCH AIM We used qualitative methods of data, obtained from surveys completed by diverse stakeholders, to explore the current AHC landscape with the goal of identifying barriers and opportunities for productive tripartite mission alignment. Our study design allowed a holistic synthesis of both conceptual and pragmatic levels of this research question, both of which are critical for generalizable knowledge. The goal of this study was to explore opportunities to reconceptualize how the tripartite missions could be better aligned and improve health for patients and populations.

| Study design
We performed an exploratory qualitative study using thematic analysis of data obtained from a survey with open-ended questions administered to several stakeholder groups. 17

| Academic health centers
We explored diverse perspectives about the education, research, and clinical missions of U.S. medical schools and their partnering health system(s). We first categorized U.S. medical schools based on their affiliation(s) with hospitals and organizational structure. Using existing definitions from the Association of American Medical Colleges, Chartis Consulting Group, and Association for Academic Health Centers, we defined an AHC as a hospital affiliated with a medical school, and "integrated" as "being under common ownership with a College of Medicine (COM), having the majority of medical school department chairperson as the hospital chiefs of service, or having the chairperson responsible for appointing the hospital chiefs of service." 9,19,20 We identified four categories of medical schools (Data S1) for this work, and identified at least one school from each (Table 1).

| Survey instrument
We developed a survey instrument for the purpose of this study (Data S2). The research team collaborated on item development, followed by eight cycles of edits, to ensure alignment with the research question. The survey was pilot tested with five faculty members and two students, resulting in several modifications. The survey was distributed and data were collected through REDCap (Research Electronic Data Capture) hosted at PSCOM. 21

| Study participants and data collection
An investigator at each AHC invited participants in seven preidentified groups representing a broad sampling of healthcare professionals (Data S3): (a) medical educators, (b) researchers, (c) health system leaders, (d) hospital administrators, (e) clinical providers, (f) resident/fellow physicians, and (g) health professions students. Investigators were encouraged to use their unique context insights and professional relationships to select participants who could provide thoughtful responses. Lead investigators sent an e-mail invitation with a survey link to five participants from each category (n = 35 at each AHC; n = 175 total); they were encouraged to invite participants from T A B L E 1 Demographics of respondents from each participating medical school and/or health system

| Data analysis
We used an exploratory qualitative design and thematic analysis approach, allowing us to enhance our understanding of research aims that have been less well addressed in the literature. 17,18,22 During data analysis, we identified our biases, specifically that this study was developed and performed primarily by educators, researchers, and physicians. 23 To address this potential bias and ensure confirmability of our results, we asked survey questions in a neutral manner, and the data analysis appropriately balanced all missions. 24 We included several crosschecks of data with research team members.
Two investigators (J.G., M.D.) used constant comparative analyses to jointly code several survey responses to generate a preliminary codebook to facilitate subsequent analysis. 17 They then analyzed half of the data, with regular adjudication sessions, to compare codes for inconsistency and agreement; the codebook was updated/modified as necessary. The remaining transcripts were analyzed independently, followed by regular adjudication sessions. Investigators discussed the emergence of higher-order themes, and further articulated the themes through discussions with co-investigators. We anticipated strategies would be identified that linked any two of three missions. To capture these results, we were sensitized to the concept of knowledge flows, or practices that result in acquisition of knowledge. Used in prior work related to aligning academic missions in Europe, knowledge flows encourage practices to promote, nurture, and align different areas. 16 In addition, based upon our prior and current work, we were open to categorizing the results within the health systems science (HSS) framework (if applicable), which is defined as the "principles, methods, and practice of improving quality, outcomes, and costs of healthcare delivery for patients and populations within systems of medical care." The HSS framework originated within education but has been advanced as critical for integrating research and operations. [25][26][27][28][29] We anticipated that several areas of synergy between the missions would be related to HSS concepts. Analysis was performed with data management support from the program Atlas.ti 6.0 (Scientific Software, Berlin, Germany). 30

| Higher-order themes
We identified five higher-order themes that spanned all missions.
These themes were not specific to any one mission, but rather highlighted the interconnected nature of each. These features are considered ideal and aspirational in the process of fully aligning AHC missions. Figure 1 depicts the relationship between all five themes. • Clinical care in academia needs to more closely align with community needs and should be the model for the community as opposed to an outlier. [educator] • Tension of economic drivers. Participants identified a tension between the three missions, with clinical operations seen as providing financial support for research and education. In particular, the education mission was often viewed as vulnerable, despite its potential to be a differentiator among competitor health systems.
Some respondents described the tension and uncertainty of seeking clinical revenues to support educational innovation. In addition, some believed financial drivers are in conflict with the needs of patients and communities.
• Even though there is a pressure to prioritize service over education, clinical leadership needs to embrace education as a core mission and make efforts to balance service and education.
[system leader] • There will always be tension among clinical, educational, and research missions. Success in education and research will inevitably mean some degree of compromise of the clinical mission. [administrator] • • Coproduction to become a learning health system. One unifying theme was the need for improving structures and work processes to allow for knowledge, vision, values, and culture to be mutually developed between stakeholders. This "coproduction" of work was believed to be a better method to achieve long-term goals and patient outcomes, and ideally occurs through collaborative work, inclusive of leadership, clinicians, and patients. Within this process, participants frequently cited the need to form new or strengthen already-existing relationships with other stakeholders, across missions and outside of AHCs. These partnerships include community organizations, clinical sites and hospitals, and patients.
• We need to shift to the framework of learning health system. This will empower all professionals to be part of the solution -clinicians inform researchers, who inform clinical/education.  • Large data sets will shed light on waste, and pinpoint inappropriate spending, which will change practice. Electronic medical records will make it possible for provider feedback to become an instrumental part of education, and "big data" will make cost-conscious care reality. [student] • I hope we see more funding for research and quality improvement that focuses on waste, stewardship of resources, variation in care, polypharmacy, and patient self-management. [administrator]

| Mission-related strategies
For each mission area, participants identified strategies that would better align each mission with AHC goals.

| Research
Participants identified several categories of strategies to align research with AHC goals. Categories included: (a) evolving research agenda that includes not only basic science and "discovery," but also patient-centered care and "delivery" research ( Developing partnerships and researchers: • [Research should] focus more on embedded research within health systems so results are meaningful across diverse stakeholders rather than research that is interesting only to a set of "like-minded" researchers. [researcher] T A B L E 3 Potential categories of enablers to enhance alignment between the research, education, and clinical missions Clinical learning environment redesign Redesign and improvement of care models and processes that support education in systems learning areas (Figure 1). • Relax the time limits that providers have with their patients, particularly if those providers are also training students.[resident/fellow trainee] • Before starting research, understand system needs regarding the topic, by bringing in focus groups of all system participants: social workers, physicians, patients, staff. [student] • Provide training opportunities for fellows, students, faculty. Develop an institutional budget that provides time for physicians to do research.
Provide mentoring for grant development. Recruit physicians with funding and robust programs, and strong clinical presence. [researcher] Operations: • As grant funding is expected to decrease, research programs need to New care delivery models and technology: • Build functional TEAM units that provide transdisciplinary care, identify social disparities, and develop systems to assist and connect patients when needed.
[system leader] • [Clinical operations need to be] more integrated, team-driven, patientcentered, outcome-driven, less hospital-centric, and highly reliable by 2027. [administrator] T A B L E 3 (Continued)

Dyad Category Description and representative quotation
• Ensuring there is enough faculty and staff for each specialty to provide care for patients, but also to allow enough time for extra medical education. [student] Recruitment and professional development Recruit faculty with skills/mindset and enhance the skill of current faculty to both transform care environments and improve education in systems areas. • Added training of all clinical preceptors we work with so they understand the importance of our mission and do not unintentionally detract from that. Provide a certificate of added qualification to preceptors who agree to go through added training to enhance their abilities as an educator. [clinical health system leader]

Clinical-Research
Clinically relevant research agenda Focus on care delivery and innovation (Figure 1).
• Research programs that help health systems determine ways to improve operational effectiveness, empower patients to be more responsible and impact their own health, and improve outcomes of care will be better aligned with AHC clinical missions. [hospital/health system administrator] • Collect data and contribute to research on clinic flow, efficacy in scheduling, treating patients, maintaining patient communication.
[resident/fellow trainee] • There should be an increase of QI research, focusing on healthcare spending/utilization to help deliver appropriate care and reduce costs.
[student] • If population health or care redesign is a goal, it will need guidance from research, so those goals are aligned. Patient factors and needs: • Focus on community-based care and prevention though healthcare positions that support optimization of social determinants of health.

[medical educator]
Value-based care: • There are efforts in every clinic to make care more efficient, accessible, and higher quality. However, efforts are disconnected -bringing stakeholders together to align missions and avoid duplicative work would allow for greater efficiency and impact. [student] • Bring the message of value-based care to all. Learn how to incorporate data to understand how we are doing in quality, patient satisfaction, cost and utilization and provider/care team satisfaction. [administrator] Clinician well-being: •  Table 3 describes these areas, with themes and quotations for each.

| DISCUSSION
A century ago, academic health centers (AHCs) emerged at the intersection of patient care, research, and education. These tripartite missions were largely embodied in people, specifically faculty known as "triple threats" for their breadth and depth of expertise in all three areas. 32,33 AHCs drew their identities from these individuals, and, in turn, supported their efforts. Medicine has changed significantly over this time period-"triple threats" are rare, and, in their absence, the previously coherent AHC identity linked to these individuals has unraveled. 34 Each mission area has become more demanding, and most faculty members operate mostly within one or two missions. 32 We can no longer depend on individual people alone to define the AHC identity-institutions need to take the lead and support the diverse individuals who can make it work. While each mission is independently important, the unique potential of the AHC to fulfill its promise in achieving the Quadruple Aim and becoming a learning health system lies in fortifying the intersection of all three missions. 2,5 This will require: (a) understanding of the perspectives of the people who comprise AHCs, (b) insight into opportunities for progress and transformation in effective mission alignment, and (c) deliberate investment by AHCs in the resources and infrastructure necessary to facilitate the learning health system journey. This study was designed to explore the voices of AHC stakeholders, and has provided insight into a way forward. Our participants articulate how each mission's strategies may inform the others in a more cohesive manner, specifically through shared vision, alignment, coproduction, and mutually shared systems concepts.
Prior work has explored alignment across missions, highlighting the need to account for economic, management, governance, and strategy considerations. 35 These works have been primarily conceptual, or propose granular strategies within research and clinical missions (eg, population health), or education and clinical missions (eg, workforce gaps). 14,36-50 Missing from this work has been the perspectives of system leaders, clinicians, scientists, and trainees who increasingly dedicate their professional careers to one mission. Uncovering these perspectives provides a fresh lens through which to visualize and address this challenge and create environments in which stakeholder voices facilitate systems level changes toward a common goal.
In the past two decades, the concept of a learning health system has emerged to conceptualize the organizational structures and processes for leveraging the iterative use of data and learning to generate knowledge and support evolving systems of care. 3 51,52 While used "vertically" within the context of healthcare delivery and redesign, our results argue for coproduction to be applied "horizontally" across missions, supporting the uncovering and evolution of a unique AHC identity. 51 Educators, researchers, and system leaders need to be equally contributing as colleagues-sharing expertise, respect, and professional investment-rather than operating from distance and encumbered by power differentials, different languages and priorities, and unaligned outcomes. If each mission continues to stay in its own lane-education in content/pedagogy, research in grants and publications, and clinical care in unaligned system initiatives-then the opportunity for AHCs to realize their unique identity as change agents capable of improving outcomes will continue to be compromised.
The second major issue relates to unifying concepts that inform the substrate of coproduction. These concepts ( Figure 1) overlap with the HSS framework, which originated within medical education but has been proposed as a unifying framework for advancing research and clinical operations. [25][26][27][28][29] HSS has the depth and reach to support coproduction across missions. Some authors have suggested more limited applications, such as a recent insightful commentary suggesting AHCs consider adding a fourth mission to the tripartite model focusing on social accountability. 39 Rather than adding a new mission, our results argue for using HSS as a conceptual framework and substrate for creating AHC strategic alignment.
The health of AHCs depends on a vibrant and strategically sound identity cultivated by a coproduction process anchored in HSS. This of an already evolving AHC identity, and a pragmatic strategy that encapsulates core tenets of a learning health system, such as the identification of key challenges, stakeholder inclusion and collaboration, and iterative use of data to inform healthcare redesign. 3,4 There are several limitations to this work. First, data were obtained from open-ended surveys sent to participants, which may limit the richness of data. However, we received a good response rate, and quantity of data was significant. Second, our five medical schools represent a small fraction of U.S. medical schools. We did sample across different medical school-health system partnerships, which increases generalizability. However, different types of medical schools, teaching hospitals, and faculty practice-group affiliations exist, and these may not have been well represented. 9 Future work could be undertaken to re-examine these findings, with particular attention to the type of medical school-health system affiliation.
Despite these limitations, we believe these results contribute to the literature related to evolving AHC missions, and provide a foundation for subsequent scholarly work.
AHCs are at a crossroads with respect to identity and alignment across the education, research, and clinical missions. The AHC identity is at risk of being co-opted by clinical operations, leaving unaligned research and education to survive on trickle-down and external funding. The voices in this study argue for research and education to join health systems as full, co-producing partners in fulfilling the AHC vision of improving the health of patients and populations. This is the challenge, and the enormous opportunity, of these unique institutions.