Sorry, you need to enable JavaScript to visit this website.
Skip to main content

Building Systems Citizenship in Health Professions Education: The Continued Call for Health Systems Science Curricula

Jed D. Gonzalo, MD, MSc, and Mamta K. Singh, MD, MSc | February 1, 2019 
View more articles from the same authors.


We will never transform the prevailing system of an organization without transforming our prevailing system of education. They are the same system.(1) Edwards Deming

The Burning Platform for Change

The Institute of Medicine's 1999 (IOM) report, To Err Is Human: Building a Safer Health System, revealed that more people die each year as a result of medical errors than from traffic accidents, breast cancer, or acquired immune deficiency syndrome.(2) These findings shocked health care into launching a movement to build safer and more reliable systems.

Nearly two decades later, slow and steady progress has been made, with reports suggesting improvements in some areas such as hospital-acquired infections.(3,4) However, the magnitude of improvement has not matched the need. Moreover, on top of these patient safety concerns, many studies have suggested the United States health care system falls short when compared to other nations on both outcomes and efficiency.

While there are many reasons for our limited progress, one is clearly the difficulty we have had in building and sustaining a culture in which health care team members communicate openly and learn from errors and mistakes. We have learned that creating such a transparent and just culture does not automatically result from building infrastructure, such as reporting systems and expanded data sharing. Instead, improving patient safety, achieving better clinical outcomes, and effectively redesigning systems of care require both educational and cultural transformation.

Resulting Changes in Health Care and Medical Education

As the need for overall system improvement has become more apparent, health care delivery is undergoing a transformation aimed at achieving the Quadruple Aim of improving patients' experiences of care, population health, work life of clinicians, and reducing cost.(5) There is an increasing focus on operational excellence within care delivery processes to ensure consistent pursuit of efficient, effective, and safe care with higher degrees of reliability.

Specifically for patient safety, an Institute for Healthcare Improvement report in 2015 offered eight recommendations to more fully achieve a culture of safety (Table).(4) While following such recommendations will undoubtedly improve organizational performance, fundamental to this change is the way in which a clinician views his or her professional identity and the education that cultivates this identity. Furthermore, the education is not just about new competencies in patient safety (i.e., how to report errors or use data to improve systems). Rather, it involves a shift in how all health care providers think and view their role—one that necessitates learning from and with team members, approaching everyday care by seeing the work through a systems thinking lens, and taking a proactive approach to system errors. It also involves recognizing how one's way of approaching gaps in care is an obligatory part of their professional identity, a state we refer to as being a systems citizen.(6-8) For such a paradigm shift, providers need to learn certain behaviors and unlearn others. They also need to embrace new skills and habits, and teams and organizations need to adopt a new way of working within the culture.(9) This systems citizenship mindset is a necessary precursor to making major improvements in patient safety.(7,8,10)

Health Systems Science

Adapting to these forces and anticipating the inevitability of even more change to come, medical education is rapidly transforming. Since the early IOM safety and quality reports 20 years ago, health professions schools, graduate medical education (GME), and undergraduate medical education (UME) have been learning to complement traditional basic and clinical sciences with cognitive and experiential learning in systems-based competencies. In the late 1990s, the Accreditation Council for Graduate Medical Education (ACGME) issued a new competency requirement in systems-based practice, which expanded into some facets of UME (e.g., patient safety, interprofessional education) and GME (e.g., quality improvement, patient safety) curricula.

Despite this call for change, as of 2012 these somewhat disjointed systems competencies had not yet become a significant component of educational programs, and educators lacked a formal framework to guide curricular redesign and evaluation. In response, many medical schools adopted a "third pillar" of medical education, known as health systems science, which complements the traditional pillars of basic and clinical sciences.(11-15) The health systems science pillar includes competencies related to health care policy, public and population health, interprofessional collaboration, clinical informatics, value-based care (including patient safety), health system improvement, and systems thinking. The comprehensive health systems science framework is now being embraced by many medical schools, residency programs, and academic health systems to better align education with the emerging needs of the care delivery system.(9,16) This pillar seeks to bring together all of the related systems competencies in a way that enhances the development of the systems citizenship mindset.(6)

We Are All One System

Medical education's effort to fully embrace a three-pillar model is not the sole decision of medical schools, education deans, or executive leadership. The larger health care system and culture must embrace and contribute to this shift for sustainable success. We are all one system, one learning environment. Without a conducive environment to not only teach the foundations of health systems science, but to reinforce these lessons for trainees in the actual clinical environment, the education will transiently rise and fall with each new cohort of learners, and progress too slowly—similar to what we have seen over the last two decades.(17) Integral to this journey is leadership at all levels, including today's faculty and providers, many of whom were educated in a system that did not focus on health systems science, and frankly, do not believe their professional role is to be a systems citizen.(18) Our students and residents need to learn from faculty mentors who demonstrate how addressing patient safety issues across the continuum for individual patients and populations of patients are critical for improving care, and how enhancing a system process should be perceived not as a task but a professional imperative.(19) Similarly, our clinical learning environments must offer safe space for such feedback and learning so health care professionals may have these discussions without fear.

In short, if we are to develop future systems citizens, we need to create the space to assert such citizenship. Only then will we achieve the level of transformation to create a culture of safety and to improve patient outcomes and health.

Jed D. Gonzalo, MD, MSc Associate Professor of Medicine and Public Health Sciences Associate Dean for Health Systems Education Penn State College of Medicine Hershey, PA

Mamta K. Singh, MD, MS Associate Professor of Medicine Assistant Dean for Health Systems Science Case Western Reserve University Cleveland, OH


1. Deming WE. Out of the Crisis. Cambridge, MA: Massachusetts Institute of Technology, Center for Advanced Engineering Study; 1986. ISBN: 9780262541152.

2. Kohn L, Corrigan J, Donaldson M, eds. To Err Is Human: Building a Safer Health System. Washington, DC: Committee on Quality of Health Care in America, Institute of Medicine. National Academies Press; 1999. ISBN: 9780309068376.

3. Clancy CM. Ten years after To Err Is Human. Am J Med Qual. 2009;24:525-528. [go to PubMed]

4. Free From Harm: Accelerating Patient Safety Improvement Ffifteen Years After To Err Is Human. Boston, MA: National Patient Safety Foundation; 2015. [Available at]

5. Bodenheimer T, Sinsky C. From triple to quadruple aim: care of the patient requires care of the provider. Ann Fam Med. 2014;12:573-576. [go to PubMed]

6. Aron DC, Headrick LA. Educating physicians prepared to improve care and safety is no accident: it requires a systematic approach. Qual Saf Health Care. 2002;11:168-173. [go to PubMed]

7. Gonzalo JD, Wolpaw T, Wolpaw D. Curricular transformation in health systems science: the need for global change. Acad Med. 2018;93:1431-1433. [go to PubMed]

8. Hafferty FW, Levinson D. Moving beyond nostalgia and motives: towards a complexity science view of medical professionalism. Perspect Biol Med. 2008;51:599-615. [go to PubMed]

9. Lucas B. Getting the improvement habit. BMJ Qual Saf. 2016;25:400-403. [go to PubMed]

10. Brennan TA. Physicians' professional responsibility to improve the quality of care. Acad Med. 2002;77:973-980. [go to PubMed]

11. Crosson FJ, Leu J, Roemer BM, Ross MN. Gaps in residency training should be addressed to better prepare doctors for a twenty-first-century delivery system. Health Aff (Millwood). 2011;30:2142-2148. [go to PubMed]

12. Gonzalo JD, Haidet P, Papp KK, et al. Educating for the 21st-century health care system: an interdependent framework of basic, clinical, and systems sciences. Acad Med. 2017;92:35-39. [go to PubMed]

13. Skochelak SE, Hawkins RE, Lawson LE, Starr SR, Borkan J, Gonzalo JD. Health Systems Science. 1st ed. Philadelphia, PA: Elsevier; 2016. ISBN: 9780323461160.

14. Skochelak SE. A decade of reports calling for change in medical education: what do they say? Acad Med. 2010;85(suppl 9):S26-S33. [go to PubMed]

15. Lucey CR. Medical education: part of the problem and part of the solution. JAMA Intern Med. 2013;173:1639-1643. [go to PubMed]

16. Gonzalo JD, Ahluwalia A, Hamilton M, Wolf H, Wolpaw DR, Thompson BM. Aligning education with health care transformation: identifying a shared mental model of "new" faculty competencies for academic faculty. Acad Med. 2018;93:256-264. [go to PubMed]

17. Improving Environments for Learning in the Health Professions: Recommendations from the Macy Foundation Conference. New York, NY: Josiah Macy Jr. Foundation; 2018. [Available at]

18. Gonzalo JD, Caverzagie KJ, Hawkins RE, Lawson L, Wolpaw DR, Chang A. Concerns and responses for integrating health systems science into medical education. Acad Med. 2018;93:843-849. [go to PubMed]

19. Batalden P, Davidoff F. Teaching quality improvement: the devil is in the details. JAMA. 2007;298:1059-1061. [go to PubMed]


Institute for Healthcare Improvement Recommendations for a Systems Approach to a Culture of Safety.(4)

(Go to table citation in the text)

1. Ensure that leaders establish and sustain a safety culture
2. Create centralized and coordinated oversight of patient safety
3. Create a common set of safety metrics that reflect meaningful outcomes
4. Increase funding for research in patient safety and implementation science
5. Address safety across the entire care continuum
6. Support the health care workforce
7. Partner with patients and families for the safest care
8. Ensure that technology is safe and optimized to improve patient safety
This project was funded under contract number 75Q80119C00004 from the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. The authors are solely responsible for this report’s contents, findings, and conclusions, which do not necessarily represent the views of AHRQ. Readers should not interpret any statement in this report as an official position of AHRQ or of the U.S. Department of Health and Human Services. None of the authors has any affiliation or financial involvement that conflicts with the material presented in this report. View AHRQ Disclaimers
Related Resources From the Same Author(s)
Related Resources