The Agency for Healthcare Research and Quality (AHRQ) developed a list of core competencies for learning health systems (LHS) to guide the development of 11 training programs and address the unique training needs of investigators leading efforts within a LHS to transform care delivery. Recently, the training program directors reviewed the competencies and added a new domain to address health and health care inequities by applying LHS science methods in health care delivery systems.

Competencies in this new domain include:

  • Assess how existing health inequities affect population-level health, individual health, and health care delivery systems with methods grounded in an awareness of the multilevel factors contributing to such inequities.
  • Apply methods to optimally engage diverse participants (including clinicians, staff, patients, community members, and caregivers) in LHS initiatives throughout each initiative, from priority-setting to design to implementation through evaluation.
  • Demonstrate awareness of the value and limitations of sub-group analyses in LHS research and improvement activities to understand heterogeneity of health system effectiveness.
  • Apply LHS knowledge and methods to translate, implement, and scale research innovations to advance equity and justice in health and health care delivery.
  • Demonstrate awareness of measurement tools related to health equity at the population, community, health care practitioner, and individual patient and community member levels.

The inclusion of this competency has the potential to amplify and sustain the growing focus on equity within health systems by making it an explicit competency on par with research methods. To do so will require broad attention from the health services research community and health care systems, the development of appropriate curricula to support the training of LHS leaders, and ultimately codification in the policies and practices of health systems.

Justice is a Foundational Principle

A welcome aspect of the domain definition is that it includes justice. This is a foundational ethical principle of health care together with autonomy, beneficence, and non-maleficence.

There are many definitions of justice. I like this one:

"Justice is generally interpreted as fair, equitable, and appropriate treatment of persons. Of the several categories of justice, the one that is most pertinent to clinical ethics is distributive justice. Distributive justice refers to the fair, equitable, and appropriate distribution of health care resources determined by justified norms that structure the terms of social cooperation."

Health systems distribute services to populations, so justice must be a key feature of how health systems function. They have the resources and opportunity to not only care for the individuals in the system; indeed, they have a responsibility to look at the overall population(s) they serve to ensure fairness in how they deploy their resources. Some health systems go beyond the obvious resource (care) to also examine their hiring and contracting practices, their impact on the environment in the communities they serve, and many other aspects of equity.

Make Intersectionality Explicit

While the LHS equity competencies do not explicitly use the term intersectionality, they point to this by acknowledging the multi-level factors and heterogeneity that must be addressed in caring for diverse populations.

As part of AcademyHealth’s diversity, equity and inclusion strategy, we released a glossary of terms where intersectionality is defined as: “Frameworks and strategies that address a vision of racial justice that embraces the intersections of race, gender, class, and the array of barriers that disempower those who are marginalized in society;” coined by Kimberle Crenshaw (African American Policy Forum, no date).

Training programs that adopt this competency should integrate an explicit focus on intersectionality.

Health Equity in Action

The five competencies include one on assessment, two on demonstrating awareness and two on applying knowledge. A bias toward action is needed today so it is critical to underscore and emphasize the two aspects related to application.

First, adequate engagement of diverse populations is a non-negotiable competency in research and care today, so the competency related to diverse engagement is well-placed. We have decades of research and practice in community based participatory research and a growing body of literature on engagement science thanks to investments from the Patient-Centered Outcomes Research Institute. The latter’s engagement literature explorer contains almost 2,500 articles! So every LHS training program should be very strong on this dimension.

Second, the competency calling for application of LHS methods to translate, implement, and scale research innovations for equity is, perhaps, the most important. Implementation research is one of the newer sub-communities within health services research and it continues to grow as NIH and other research funders dedicate additional resources. One proxy indicator of the increase of this type of research is the sustained growth of the Annual Science of Dissemination and Implementation Research conference, which is in its 15th year in 2022. Yet too little of its work has focused squarely on equity so there is much progress to be made!

A previous AcademyHealth blog proposed five recommendations for advancing achieving equitable implementation, calling out the implicit biases that may limit the effectiveness of our current methods. Some of the authors of this blog were also responsible for an excellent special issue on equitable implementation in the Stanford Social Innovation Review in 2021. LHS training programs would do well to ensure explicit content in their curriculum on equitable implementation.

AHRQ is to be commended for this addition to the LHS competencies and AcademyHealth stands ready to support its widespread adoption and use. It will also be important to learn from its implementation and hope that training program directors and funders will work collaboratively to assess curricular innovations, barriers, and facilitators to implementation, and ultimately the scope and scale of the competency’s implementation and - most importantly - its impact.

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