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 Table of Contents  
Year : 2019  |  Volume : 9  |  Issue : 2  |  Page : 77-82  

Applying systems approach for bridging education, research, and patient care in a health sciences university

1 Centre for Health Professions Education, Sri Balaji Vidyapeeth (Deemed University), Puducherry, India
2 Vice Chancellor, Sri Balaji Vidyapeeth (Deemed University), Puducherry, India

Date of Acceptance29-Aug-2019
Date of Web Publication18-Sep-2019

Correspondence Address:
B V Adkoli
Centre for Health Professions Education, Sri Balaji Vidyapeeth (Deemed University), Puducherry - 607 402
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/tp.TP_49_19

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Systems approach provides a logical and scientific basis for explaining the functioning of a system in a holistic manner. The health sciences university is a system with its three major operations – education, research, and patient care, which can be conceived as inputs, process, and output, respectively. The system is aided by a feedback loop to inform and correct the system. Systems thinking enable us to identify the deficiencies existing in each of the components so that appropriate remedial action can be taken. In this article, we have identified deficiencies in the health sciences system. Further, we have suggested a five-point formula to achieve connection among education, research, and patient care. We need to Form consortia and networks to create a mass movement, Uniform regulations to remove bottlenecks, Reform curricula to make them credit linked and competency based, Inform all through a faculty development initiative, and finally, Transform the system by setting examples and demonstrating success. The initiative taken by the Medical Council of India in introducing a competency-based curriculum for MBBS, and the revised accreditation manual introduced by the National Assessment and Accreditation Council can provide a lot of opportunities to explore the potentiality educational research to answer many questions that can help us in connecting research with education and patient care.

Keywords: Accreditation, evaluation and feedback, health sciences university, medical education, quality assurance, systems approach

How to cite this article:
Adkoli B V, Parija S C. Applying systems approach for bridging education, research, and patient care in a health sciences university. Trop Parasitol 2019;9:77-82

How to cite this URL:
Adkoli B V, Parija S C. Applying systems approach for bridging education, research, and patient care in a health sciences university. Trop Parasitol [serial online] 2019 [cited 2022 Dec 4];9:77-82. Available from: https://www.tropicalparasitology.org/text.asp?2019/9/2/77/267139

   Introduction Top

There has been growing interest in almost every field of human knowledge to apply systems approach to address and solve their problems. We discussed the meaning and application of systems approach in education in our previous article.[1] We also cited the advantages of systems approach in solving problems and in achieving the effectiveness and efficiency of the system.

In the present article, we will discuss about the gap that exists among the three most important components, namely, education, research, and patient care in the functioning of a health sciences university. We show with relevant examples how can we bridge this gap by following the systems approach.

Systems approach is a holistic concept. A system dynamically interacts with the external environment in a continuous manner in trying to achieve its goals. All systems have three essential components – inputs, process, and output. These are linked by a feedback loop to monitor and regulate the effective functioning of the system. Although the quality of inputs largely contributes to the quality of output, this cannot be guaranteed if the process is flawed. However, if the process is efficient, it can optimize the output. A key feature of a dynamic system is presence of a feedback loop which can correct the process as well as send signal to modify the quality and quantity of inputs [Figure 1].
Figure 1: Systems view of the health-care delivery system

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A Health Sciences University System (HSUS) is a dynamic system which functions as a subsystem and interacts with other systems such as general/higher/technical education, agriculture, economy, commerce and business, politics, humanities, and art and culture, all contributing to human welfare. The key stakeholders, here are (a) civil society who are the consumers of the health care delivery, engaged in defining their needs as well as supplying “inputs” in the form of students, (b) the governments including central and state who lay down policies and at times finance directly or indirectly, (c) the regulatory bodies (various councils) and accrediting agencies who are the custodians of quality, and (d) global market forces that influence the demand and supply chain.

Education or precisely knowledge is a major input. Research is the process by which knowledge gets converted into either advanced knowledge or application in the form of output. The application leads to improved patient care services. The advanced knowledge is again fed back to the system as input.

The goal of health science university is to create new knowledge or apply existing knowledge to train a health workforce that will be able to provide robust health-care services to the society. This encompasses not only access to quality health-care services but also to ensure the well-being of the individuals and the community. Every society needs knowledge, creativity, and innovation to fuel its economy. The economy stimulates development and the development leads to welfare. This can be achieved by the universities who are hopefully, the largest producers and distributors of knowledge. A list of various inputs, process, and output have been outlined in [Table 1].
Table 1: Systems view of health sciences university system

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   Inputs Top

Education, which deals with knowledge, is the main input. However, there are other inputs that are part and parcel of education. They are previous knowledge, skills, and attitudes of students and teachers, resources in terms of manpower, material, and money (the 3 M's), besides a curriculum that provides for formal and informal learning experiences through schooling, coaching, or socializing via social media. One of the untapped inputs in this system is the knowledge and wisdom which is hidden in the society in the form of cultural traditions which can be invaluable source of learning.

   Process Top

The process component of health sciences system which is most complex and least understood (black box) consists of evidence-based mechanisms. Teaching, learning, and evaluation based on research evidence (both quantitative and qualitative), and quality assurance mechanisms such as feedback and mentoring. The motivation level of all stakeholders is also a key process which can be argued as an input too.

   Output Top

The main output of the HSUS consists of trained graduates and experienced faculty, who are competent and capable of delivering better health outcomes. The output also includes new knowledge or the application of existing knowledge in the form of IPRs which lead to improved service. They also bring financial returns to the university through technology transfer to the industries. This helps the universities to sustain their activities. The new knowledge is recycled again as an input for further research.

The beauty of systems thinking lies in the fact that, a reverse engineering is also possible. We can start by using the established patient care services and well-being practices known to humankind as the inputs to the system. By subjecting them to the process of research scrutiny, we can produce output in the form of advanced human knowledge. Converting basic sciences research in to a stage-wise application, namely, clinical trials, clinical guidelines, community application, and ultimately, public health application and universal practice have now emerged as translational research.[2] Application of systems approach helps in minimizing the inputs, especially the resources and workforce, optimizing the process, and maximizing the output. For example, it has been shown that patient satisfaction is largely associated with communication skills. The main input here is a student who enters with low level of communication skills, faculty who are trained and skilled, a curriculum which is innovative and resources which are available and accessible. The process is the way instruction is designed for effective learning of communication skills, using simulated cases, role-play, video-based modules, and coaching by role models. The outputs produced are the students trained in communication skills who demonstrate these skills in their workplace and enhance patients' satisfaction.

The disconnect among education, research, and patient care

Some of the main deficiencies existing in the HSSU with regard to education (input), research (process), and patient care (output) have been listed in [Table 2].
Table 2: Deficiencies existing in the health sciences system

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Historically, medical education has been largely disconnected from research and patient care. The disciplinary and departmental approaches to the curriculum and modern medicine have made a deep impact on the Indian Medical Education System. The acquisition of knowledge without emphasis on skills has been affected by phenomenal increase in the number of medical colleges, enrolment of students, selection process largely based on Multiple Choice Questions (MCQs) and shortage of faculty and clinical resources which are inputs of the system.[3]

The lack of evidence-based teaching-learning and evaluation coupled with the absence of feedback loop are largely responsible for deteriorating the quality of process. The absence of mechanisms of quality assurance, control exercised by multiple agencies and regulators, lack of pro-active intervention, and finally the resistance to change are also responsible for the state of affair. Good practice of teaching needs to be supported by evidence which requires educational research. Educational research in health sciences university is yet to take off in the Indian soil. This is again due to factors such as individual lack of awareness and expertise, organizational hurdle such as lack of funds or delay in approvals, and most importantly, lack of motivation and recognition of educational research.[4] Fortunately, things are changing and the time has come to broaden the scope of research.

The new buzz word in education is competency-based medical education (CBME) which has received global attention.[5] In response to this global trend, The Medical Council of India has taken initiative in initiating CBME for the MBBS program as a part of Graduate Medical Education Regulations.[6] Few progressive medical colleges and Universities have taken serious steps to ensure the preparedness of faculty to launch the revised curriculum.

The introduction of foundation course, early exposure of undergraduates to the community, incorporation of Attitude, Ethics and Communication Modules throughout the course, stress on integrated teaching, introduction of electives, and structured internship are all laudable objectives to pursue.[7] These should be looked upon as opportunities for coming out with educational research projects to create evidence. More importantly, there is a need to design multicentric research studies to result in authenticity, validity, reliability, reproducibility besides feasibility and acceptability.

While MCI initiatives are the drivers for initiating medical education research, the new Guidelines for Health Sciences Universities introduced by the National Assessment and Accreditation Council (NAAC) provide another golden opportunity for the health sciences universities to take up educational research.[8] The revised NAAC criteria cover seven criteria which are further divided into key indicators, and in turn, into metrices which are measurable quantitatively and qualitatively. While these have been introduced after several rounds of consultation by the experts and pilot testing, it is reasonable to state that we need to establish validity, reliability, and feasibility with robust multicentric research design considering the diversities of the country. Longitudinal studies are also needed to assess the predictive validity of the instrument. This is extremely challenging considering the pace in which knowledge is expanding, and technology is revolutionizing everyday.

Some interesting research questions emanating from NAAC criteria are listed [Table 3]. These can be considered as low-hanging fruits in terms of educational research.
Table 3: Research questions emanating from revised guidelines for accreditation by the National Assessment and Accreditation Council

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Suggestions for bringing synergy into system – The five-point formula

  1. Form
  2. Uniform
  3. Reform
  4. Inform
  5. Transform.

Form consortia to understand the dynamics of the system (dialogue among all stakeholders)

To address large complex systems, the only way is to create consortia and network of individuals, associations, and professions to come together. There are innumerable number of associations which focus on academics (discipline wise), research, and patient care in their own way. Networking within health profession (medical, dental nursing, and allied health sciences) to promote interprofessional education is a challenging issue. One can imagine the sensitivities involved in establishing collaboration with organizations and associations beyond health science system. However, such attempts are worth trying, and ultimately, they will result in rich dividends.

Uniform regulators and policy-makers

While regulators are the backbone for ensuring, sustaining, and enhancing quality, their role in advancing health sciences universities is beset with problems such as “multiple rules of the game” often conflicting, complexities of data gathering process, tempting the universities to project false and fabricated data to boost up the recognition or accreditation in a competitive environment. Perhaps, the new developments in technology such as big data analytics, machine language, and artificial intelligence are likely to come out with solutions which can result in regulations becoming more transparent, user-friendly, and “enabling” rather than “curbing” the initiatives by institutes which are progressive and forward looking.

Reform curriculum – Make it “knowledge-powered, research-driven, patient care focused;” break the silos, move away from formal to informal, disciplinary to transdisciplinary; classrooms to community and workplaces

Curriculum reforms are perhaps the most challenging tasks for the health science university systems. Learning lessons from the successful launching of Choice-Based Credit System by the UGC/NAAC,[9] and the initiative taken by the MCI to launch CBME, it is possible to introduce a new curriculum framework for all programs run by the Health Science Universities. While the details should be work out after extensive debate at all levels, we can suggest certain guiding principles as follows:

  • The curriculum of all programs at all levels should follow a competency-based model. This includes defining the competencies; stating milestones; providing learning experiences to be expected at each level; monitoring and assessing progress in a continuous manner.[10]
  • The educational program at each level should be problem based and research driven fitting with the level of undergraduates, postgraduates, and doctorate/specialist training programs. Obviously, research projects should become the springboards for gathering knowledge and applying the same for effective patient care. The boundaries existing among departments, disciplines, and professions must give way to an integrated and seamless curriculum guided by faculty and mentors across the disciplines
  • A common foundation program should be introduced at each level to sensitize the learners on core knowledge and core skills including study skills, life skills, research skills, communication skills besides awareness of health needs, National Health Programs, AYUSH, environmental issues, biosafety, gender sensitivity, humanities, and civic and human rights. They should also be exposed to wider range of methods, tools, and techniques, including program evaluation and qualitative research[11]
  • Considering the potentiality if E-learning and social media, tomorrows curriculum should be flexible, accessible, and engaging the students on 24 × 7 basis in a global setting.

Inform faculty – Sensitize, train, handhold, empower, and delegate

  • Faculty Development Program (FDP) is the cornerstone for ensuring the quality of teaching, learning, and evaluation. MCI has recognized its importance and has launched a national FDP comprising of Nodal Centers, Regional Centers across the country.[12] The FDPs of tomorrow should move away from the narrow scope of teacher training or pedagogy. The FDPs should be designed in such a way that it enables the teachers to implement curriculum which is research driven, problem based. FDP should also be seen in the larger canvas of “scholarship development,” which is currently gaining movement. This recognizes four types of scholarship which are relevant to HSUS, namely, (a) the scholarship of teaching, (b) scholarship of research, (c) scholarship of applications, and (d) scholarship of integration[13]
  • The FDPs should be based on sound educational principles,[14] flexible in their design, and interprofessional in their character for breaking the silos. The FDP should make optimum utilization of technology. All FDPs should be linked with their outcomes, which can be quantified or qualified, and their impact should be assessed later. A rational method of assigning credit points, for each FDP should be worked out and linked with performance approval of the faculty at all levels.

Transform the system – “Let me start first” – Dream, design, and demonstrate

The fifth and final suggestion relates to the management of change in an organization. We fully appreciate the complexities of systems, the bureaucratic hurdles, ego clashes, and power equations at every level. However, there is no option except to accept the system as it is and to work back individually in contributing to this gigantic task. This will mean internal motivation, commitment, and the zeal to crusade against odds. An effective leadership, team building, delegation of tasks, extensive communication, handholding and monitoring, and finally, encouraging the good work are all important strategies to bring about change.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1]

  [Table 1], [Table 2], [Table 3]

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