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

Leadership is vital to a well-functioning and effective health system. This importance was underscored during the COVID-19 pandemic. As disparities in infection and mortality rates became pronounced, greater calls for equity-informed healthcare emerged. These calls led some leaders to use the Learning Health System (LHS) approach to quickly transform research into healthcare practice to mitigate inequities causing these rates. The LHS is a relatively new framework informed by many within and outside health systems, supported by decision-makers and financial arrangements and encouraged by a culture that fosters quick learning and improvements. Although studies indicate the LHS can enhance patients' health outcomes, scarce literature exists on health leaders' use and incorporation of equity into the LHS. This article begins addressing this gap by examining how equity can be incorporated into LHS activities and discussing ways leaders can ensure equity is considered and achieved in rapid learning cycles.

Fairness for Whom? Learning Health Systems' Approach to Equity in Healthcare.

Many healthcare systems use "equity" as a catch-all term to underscore their commitment to delivering care matching users' needs. Despite its ubiquity, it is often haphazardly used and applied to care and improvement efforts. As the learning health systems (LHSs) approach gains prominence, LHS researchers have sought to embed equity into their work while navigating systems with differing views of equity. We examine several components of equity, its definitions within LHSs and knowledge from LHSs' equity approach that could be implemented across systems. We conclude by suggesting various ways in which readers can embed equity into their respective LHSs.

Institutional boundaries and the challenges of aligning science advice and policy dynamics: the UK and Canada in the time of COVID-19.

This comparison of institutions of science advice during COVID-19 between the Westminster systems of England/UK and Ontario/Canada focuses on the role of science in informing public policy in two central components of the response to the pandemic: the adoption of non-pharmaceutical interventions (NPIs) and the procuring of vaccines. It compares and contrasts established and purpose-built bodies with varying degrees of independence from the political executive, and shows how each attempted to manage the tensions between scientific and governmental logics of accountability as they negotiated the boundary between science and policy. It uses the comparison to suggest potential lessons about the relative merits and drawbacks of different institutional arrangements for science advice to governments in an emergency.

Saying and doing are different things: a scoping review on how health equity is conceptualized when considering healthcare system performance.

INTRODUCTION: Ensuring healthcare systems provide equitable, high quality care is critical to their users' overall health and wellbeing. Typically, systems use various performance frameworks and related indicators to monitor and improve healthcare. Although these frameworks usually include equity, the extent that equity is reflected in these measurements remains unclear. In order to create a system that meets patients' needs, addressing this uncertainty is important. This paper presents findings from a scoping review that sought to answer the question 'How is equity conceptualized in healthcare systems when assessing healthcare system performance?'. METHODS: Levac's scoping review approach was used to locate relevant articles and create a protocol. Included, peer-reviewed articles were published between 2015 to 2020, written in English and did not discuss oral health and clinician training. These healthcare areas were excluded as they represent large, specialized bodies of literature beyond the scope of this review. Online databases (e.g., MEDLINE, CINAHL Plus) were used to locate articles. RESULTS: Eight thousand six hundred fifty-five potentially relevant articles were identified. Fifty-four were selected for full review. The review yielded 16 relevant articles. Six articles emanated from North America, six from Europe and one each from Africa, Australia, China and India respectively. Most articles used quantitative methods and examined various aspects of healthcare. Studies centered on: indicators; equity policies; evaluating the equitability of healthcare systems; creating and/or testing equity tools; and using patients' sociodemographic characteristics to examine healthcare system performance. CONCLUSION: Although equity is framed as an important component of most healthcare systems' performance frameworks, the scarcity of relevant articles indicate otherwise. This scarcity may point to challenges systems face when moving from conceptualizing to measuring equity. Additionally, it may indicate the limited attention systems place on effectively incorporating equity into performance frameworks. The disjointed and varied approaches to conceptualizing equity noted in relevant articles make it difficult to conduct comparative analyses of these frameworks. Further, these frameworks' strong focus on users' social determinants of health does not offer a robust view of performance. More work is needed to shift these narrow views of equity towards frameworks that analyze healthcare systems and not their users.

Aligning goals of for-profit, not-for-profit, and public healthcare organizations by governing for quality: A model for change in the U.S. and other jurisdictions.

There has been widespread criticism of privately owned or operated healthcare organizations in Canada and beyond. However, governments have limited resources to infuse the capital and provide the scale necessary to rapidly address the post-pandemic needs of healthcare systems. Ensuring that healthcare providers regardless of ownership or for-profit or not-for-profit status, provide high quality care and ensure health equity is paramount. Here, we propose the use of a governance for quality model based on the Excellent Care for All Act (2010) developed for public hospitals in Ontario for all healthcare organizations regardless of ownership or profit status, to better align all forms of healthcare providers with quality outcomes and equitable and positive patient experience. We believe that this framework is applicable to healthcare organizations both public and private, for-profit and not-for-profit in Canada, the U.S. and beyond.

Addressing Health-Related Quality of Life Among Children With Multiple Sclerosis.

BACKGROUND: Children with the chronic disease multiple sclerosis (MS) report lower health-related quality of life (HRQOL) compared with children who experience transient illness. The relationship between an MS diagnosis and the HRQOL of affected children is mediated by parental HRQOL. Interventions to improve the HRQOL of children with MS should, therefore, include parents of affected children. METHODS: We performed a configurative review for improvements in the HRQOL of children facing diseases similar to MS and their parents. We used the generated concepts to form theories. Next, we performed qualitative interviews with clinicians who care for children with MS to characterize overlap between the proposed theories and usual care. Finally, we generated recommendations for improving the HRQOL of children with MS and their parents. RESULTS: We theorize that the HRQOL of children with MS and their parents may be improved by strengthening self-concept, hope, and knowledge. Qualitative interviews with 7 clinicians who care for children with MS revealed no common psychosocial care protocol. The interviews did, however, reveal sources of psychosocial care that overlap with the proposed theories and barriers to optimizing such care. CONCLUSIONS: Grounded in theory and clinically oriented practice, recommendations to improve the HRQOL of children with MS and their parents are to implement standardized screening, pool provider counseling strategies, create computer applications with psychosocial interventions, promote age-appropriate education resources, and secure positions for MS specialists.

Family health conditions and parental occupational status modify the relationship between pediatric-onset multiple sclerosis and parental health-related quality of life.

BACKGROUND: The health-related quality of life (HRQoL) of children with multiple sclerosis (MS) is mediated by the HRQoL of their parents. Understanding factors that modify the relationship between the child's MS diagnosis and parental HRQoL would inform interventions to improve the HRQoL of both parents and children living with MS. OBJECTIVE: We evaluated whether the association between an MS diagnosis during childhood and parental HRQoL is modified by the presence of a family health condition or low socioeconomic position (SEP). METHODS: Parents of children with MS or the transient illness, monophasic-acquired demyelinating syndromes (monoADS), were enrolled in a prospective Canadian study. Multivariable models evaluated whether the association between a child's MS diagnosis (vs. monoADS) and parental HRQoL was modified by ⩾1 family health conditions or low SEP. RESULTS: Two hundred seven parents and their children with MS (n = 65) or monoADS (n = 142) were included. We found a synergistic effect of an MS diagnosis and a family health condition on parental HRQoL. We also found a synergistic effect of having MS and a low SEP on parental HRQoL. CONCLUSION: Parents of children with MS who have another family health condition or a low SEP are at particularly high risk for low HRQoL.

How Do We Build the Human Capital for a True Learning Healthcare System?

Our healthcare systems depend on human capital for effectiveness. The Canadian Institutes of Health Research - Institute of Health Services and Policy Research has prioritized building capacity for "solution-oriented research and evidence-informed health care system transformation" (CIHR IHSPR 2021a: 20) as a core strategic direction. In this commentary, we articulate strategies for positioning PhD-trained scientists at the forefront of this transformation, including refreshing a competency framework that outlines the skill set required for maximum impact, exploring opportunities to expand embedded research career pathways and considering new ways to support the evolution of learning health systems. We conclude highlighting the need to modernize how real-world research impact is recognized.

The determinants of effective inter-organization information sharing in the health capital planning process.

This qualitative study examines the determinants of effective inter-organization information sharing in the Health Capital Planning process (the process), primarily in the final stage of the process which focuses on the review of final expenses and release of a holdback. Using thematic analysis and building off a scoping review that was conducted in preparation for this study, we provide a framework for effective information sharing during the process. We interviewed 17 leaders from the Government of Ontario and hospitals across the province. The results of the interviews indicate that the most essential determinants of effective inter-organization information sharing in the process: organizational characteristics; reducing complex bureaucracies; preserving human resources and expertise; clear and standardized information; reducing policy changes; networks; negotiation abilities; information technology; training; record retention; and early planning. This study confirmed the need for effective intra-organization and interpersonal information sharing to achieve successful inter-organization information sharing.

The health-related quality of life of children with multiple sclerosis is mediated by the health-related quality of life of their parents.

BACKGROUND: We previously found that children with the chronic disease multiple sclerosis (MS) reported lower health-related quality of life (HRQoL) when compared to children who experienced the transient illness termed monophasic acquired demyelinating syndromes (monoADS). Parents of children with MS also reported lower HRQoL. OBJECTIVES: We evaluated whether parental HRQoL mediated the relationship between the diagnosis of MS and the HRQoL of affected children. To ascertain the effect of an MS diagnosis, we compared children with MS to those with monoADS. METHODS: Children were enrolled in a prospective multi-site Canadian study. Random effects models evaluated whether parental HRQoL mediated the relationship between the diagnosis of MS and the HRQoL of affected children, adjusting for child and family characteristics. RESULTS: 207 parent-child dyads (65 MS; 142 monoADS) completed HRQoL questionnaires. When we modeled the child's HRQoL adjusting for covariates, but not the parent's HRQoL, the diagnosis of MS associated with lower HRQoL of the child (p = 0.004). When we added parental HRQOL to the model, the association between the diagnosis of MS and the child's HRQoL diminished (p = 0.13). CONCLUSIONS: Parental HRQoL mediated the relationship between the diagnosis of MS and the HRQoL of affected children, emphasizing the importance of family-centered care.

Ontario's COVID-19 Modelling Consensus Table: mobilizing scientific expertise to support pandemic response.

SETTING: COVID-19 has highlighted the need for credible epidemiological models to inform pandemic policy. Traditional mechanisms of commissioning research are ill-suited to guide policy during a rapidly evolving pandemic. At the same time, contracting with a single centre of expertise has been criticized for failing to reflect challenges inherent in specific modelling approaches. INTERVENTION: This report describes an alternative approach to mobilizing scientific expertise. Ontario's COVID-19 Modelling Consensus Table (MCT) was created in March 2020 to enable rapid communication of credible estimates of the impact of COVID-19 and to accelerate learning on how the disease is spreading and what could slow its transmission. The MCT is a partnership between the province and academic modellers and consists of multiple groups of experts, health system leaders, and senior decision-makers. Armed with Ministry of Health data, the MCT meets once per week to share results from modelling exercises, generate consensus judgements of the likely future impact of COVID-19, and discuss decision-makers' priorities. OUTCOMES: The MCT has enabled swift access to data for participants, a structure for developing consensus estimates and communicating these to decision-makers, credible models to inform health system planning, and increased transparency in public reporting of COVID-19 data. It has also facilitated the rapid publication of research findings and its incorporation into government policy. IMPLICATIONS: The MCT approach is one way to quickly draw on scientific advice outside of government and public health agencies. Beyond speed, this approach allows for nimbleness as experts from different organizations can be added as needed. It also shows how universities and research institutes have a role to play in crisis situations, and how this expertise can be marshalled to inform policy while respecting academic freedom and confidentiality.

RéSUMé: LIEU: La COVID-19 a mis en évidence le besoin de modèles épidémiologiques crédibles pour éclairer la politique pandémique. Les mécanismes habituels pour commander des travaux de recherche sont peu propices à orienter les politiques lors d'une pandémie qui évolue rapidement. En même temps, la passation de contrats avec un seul centre d'expertise est critiquée, car elle ne tient pas compte des difficultés inhérentes de certaines approches de modélisation. INTERVENTION: Le présent rapport décrit une approche de rechange pour mobiliser le savoir scientifique. L'Ontario a créé en mars 2020 une Table de concertation sur la modélisation (TCM) qui permet de communiquer de façon rapide et fiable les estimations des effets de la COVID-19 et d'apprendre plus vite comment la maladie se propage et ce qui pourrait en ralentir la transmission. La TCM, un partenariat entre les modélisateurs de la province et des milieux universitaires, est composée de plusieurs groupes d'experts, de dirigeants du système de santé et de décideurs de haut niveau. Armée des données du ministère de la Santé, la TCM se réunit une fois par semaine pour partager les résultats d'exercices de modélisation, générer des jugements consensuels sur les futurs effets probables de la COVID-19 et discuter des priorités des décideurs. RéSULTATS: La TCM rend possible un accès rapide aux données pour les participants, une structure pour élaborer des estimations consensuelles et les communiquer aux décideurs, des modèles fiables pour éclairer la planification du système de santé, ainsi qu'une transparence accrue dans la communication des données sur la COVID-19 au public. Elle facilite aussi la publication rapide des résultats de recherche et leur intégration dans la politique gouvernementale. CONSéQUENCES: L'approche de la TCM est un moyen d'obtenir rapidement des conseils scientifiques à l'extérieur du gouvernement et des organismes de santé publique. Au-delà de sa rapidité, cette approche offre une grande souplesse, car des experts de différents organismes peuvent être ajoutés au besoin. Elle montre aussi que les universités et les établissements de recherche ont un rôle à jouer dans les situations de crise, et qu'il est possible de mobiliser leurs compétences pour éclairer les politiques tout en respectant la liberté et la confidentialité des milieux de la recherche et de l'enseignement.

Effects of hospital funding reform on wait times for hip fracture surgery: a population-based interrupted time-series analysis.

BACKGROUND: Health care funding reforms are being used worldwide to improve system performance but may invoke unintended consequences. We assessed the effects of introducing a targeted hospital funding model, based on fixed price and volume, for hip fractures. We hypothesized the policy change was associated with reduction in wait times for hip fracture surgery, increase in wait times for non-hip fracture surgery, and increase in the incidence of after-hours hip fracture surgery. METHODS: This was a population-based, interrupted time series analysis of 49,097 surgeries for hip fractures, 10,474 for ankle fractures, 1,594 for tibial plateau fractures, and 40,898 for appendectomy at all hospitals in Ontario, Canada between April 2012 and March 2017. We used segmented regression analysis of interrupted monthly time series data to evaluate the impact of funding reform enacted April 1, 2014 on wait time for hip fracture repair (from hospital presentation to surgery) and after-hours provision of surgery (occurring between 1700 and 0700 h). To assess potential adverse consequences of the reform, we also evaluated two control procedures, ankle and tibial plateau fracture surgery. Appendectomy served as a non-orthopedic tracer for assessment of secular trends. RESULTS: The difference (95 % confidence interval) between the actual mean wait time and the predicted rate had the policy change not occurred was - 0.46 h (-3.94 h, 3.03 h) for hip fractures, 1.46 h (-3.58 h, 6.50 h) for ankle fractures, -3.22 h (-39.39 h, 32.95 h) for tibial plateau fractures, and 0.33 h (-0.57 h, 1.24 h) for appendectomy (Figure 1; Table 3). The difference (95 % confidence interval) between the actual and predicted percentage of surgeries performed after-hours - 0.90 % (-3.91 %, 2.11 %) for hip fractures, -3.54 % (-11.25 %, 4.16 %) for ankle fractures, 7.09 % (-7.97 %, 22.14 %) for tibial plateau fractures, and 1.07 % (-2.45 %, 4.59 %) for appendectomy. CONCLUSIONS: We found no significant effects of a targeted hospital funding model based on fixed price and volume on wait times or the provision of after-hours surgery. Other approaches for improving hip fracture wait times may be worth pursuing instead of funding reform.

Divergent notions of "quality" in healthcare policy implementation: a framing perspective.

PURPOSE: This paper examines how "quality" was framed in the design and implementation of a policy to reform hospital funding and associated care delivery. The aims of the study were: (1) To describe how government policy-makers who designed the policy and managers and clinicians who implemented the policy framed the concept of "quality" and (2) To explore how frames of quality and the framing process may have influenced policy implementation. DESIGN/METHODOLOGY/APPROACH: The authors conducted a secondary analysis of data from a qualitative case study involving semi-structured interviews with 45 purposefully selected key informants involved in the design and implementation of the quality-based procedures policy in Ontario, Canada. The authors used framing theory to inform coding and analysis. FINDINGS: The authors found that policy designers perpetuated a broader frame of quality than implementers who held more narrow frames of quality. Frame divergence was further characterized by how informants framed the relationship between clinical and financial domains of quality. Several environmental and organizational factors influenced how quality was framed by implementers. ORIGINALITY/VALUE: As health systems around the world increasingly implement new models of governance and financing to strengthen quality of care, there is a need to consider how "quality" is framed in the context of these policies and with what effect. This is the first framing analysis of "quality" in health policy.

Effects of quality-based procedure hospital funding reform in Ontario, Canada: An interrupted time series study.

BACKGROUND: The Government of Ontario, Canada, announced hospital funding reforms in 2011, including Quality-based Procedures (QBPs) involving pre-set funds for managing patients with specific diagnoses/procedures. A key goal was to improve quality of care across the jurisdiction. METHODS: Interrupted time series evaluated the policy change, focusing on four QBPs (congestive heart failure, hip fracture surgery, pneumonia, prostate cancer surgery), on patients hospitalized 2010-2017. Outcomes included return to hospital or death within 30 days, acute length of stay (LOS), volume of admissions, and patient characteristics. RESULTS: At 2 years post-QBPs, the percentage of hip fracture patients who returned to hospital or died was 3.13% higher in absolute terms (95% CI: 0.37% to 5.89%) than if QBPs had not been introduced. There were no other statistically significant changes for return to hospital or death. For LOS, the only statistically significant change was an increase for prostate cancer surgery of 0.33 days (95% CI: 0.07 to 0.59). Volume increased for congestive heart failure admissions by 80 patients (95% CI: 2 to 159) and decreased for hip fracture surgery by 138 patients (95% CI: -183 to -93) but did not change for pneumonia or prostate cancer surgery. The percentage of patients who lived in the lowest neighborhood income quintile increased slightly for those diagnosed with congestive heart failure (1.89%; 95% CI: 0.51% to 3.27%) and decreased for those who underwent prostate cancer surgery (-2.08%; 95% CI: -3.74% to -0.43%). INTERPRETATION: This policy initiative involving a change to hospital funding for certain conditions was not associated with substantial, jurisdictional-level changes in access or quality.

Association between the regional variation in premature mortality and immigration in Ontario, Canada.

OBJECTIVES: Health region differences in immigration patterns and premature mortality rates exist in Ontario, Canada. This study used linked population-based databases to describe the regional proportion of immigrants in the context of provincial health region variation in premature mortality. METHODS: We analyzed all adult premature deaths in Ontario from 1992 to 2012 using linked population files, Canadian census, and death registry databases. Geographic boundaries were analyzed according to 14 health service regions, known as Local Health Integration Networks (LHINs). We assessed the role of immigrant status and regional proportion of immigrants in the context of these health region variations and assessed the contribution using sex-specific multilevel negative binomial models, accounting for age, individual- and area-level immigration, and area-level material deprivation. RESULTS: We observed significant premature mortality variation among health service regions in Ontario between 1992 and 2012. Average annual rates ranged across LHINs from 3.03 to 6.40 per 1000 among males and 2.04 to 3.98 per 1000 among females. The median rate ratio (RR) decreased for men from 1.14 (95% CI 1.06, 1.19) to 1.07 (95% CI 1.00, 1.11) after adjusting for year, age, area-based material deprivation, and individual- and area-level immigration, and among females reduced from 1.13 (95% CI 1.05, 1.18) to 1.04 (95% CI 1.00, 1.05). These adjustments explained 84.1% and 94.4% of the LHIN-level variation in males and females respectively. Reduced premature mortality rates were associated with immigrants compared with those for long-term residents in the fully adjusted models for both males 0.43 (95% CI 0.42, 0.44) and females 0.45 (0.44, 0.46). CONCLUSION: The findings demonstrate that health region differences in premature mortality in Ontario are in part explained by individual-level effects associated with the health advantage of immigrants, as well as contextual area-level effects that are associated with regional differences in the immigrant population. These factors should be considered in addition to health system factors when looking at health region variation in premature deaths.

Are we prepared? The development of performance indicators for public health emergency preparedness using a modified Delphi approach.

BACKGROUND: Disasters and emergencies from infectious diseases, extreme weather and anthropogenic events are increasingly common. While risks vary for different communities, disaster and emergency preparedness is recognized as essential for all nation-states. Evidence to inform measurement of preparedness is lacking. The objective of this study was to identify and define a set of public health emergency preparedness (PHEP) indicators to advance performance measurement for local/regional public health agencies. METHODS: A three-round modified Delphi technique was employed to develop indicators for PHEP. The study was conducted in Canada with a national panel of 33 experts and completed in 2018. A list of indicators was derived from the literature. Indicators were rated by importance and actionability until achieving consensus. RESULTS: The scoping review resulted in 62 indicators being included for rating by the panel. Panel feedback provided refinements to indicators and suggestions for new indicators. In total, 76 indicators were proposed for rating across all three rounds; of these, 67 were considered to be important and actionable PHEP indicators. CONCLUSIONS: This study developed an indicator set of 67 PHEP indicators, aligned with a PHEP framework for resilience. The 67 indicators represent important and actionable dimensions of PHEP practice in Canada that can be used by local/regional public health agencies and validated in other jurisdictions to assess readiness and measure improvement in their critical role of protecting community health.

Training for Impact: PhD Modernization as a Key Resource for Learning Health Systems.

The Institute of Medicine (IOM) has articulated a vision of a learning health system (LHS) as one that provides the best care at lower costs and that constantly, systematically and seamlessly improves based on data and evidence (IOM 2013). The IOM identifies the four foundational characteristics of an LHS as the real-time use of data and informatics to capture the care experience, patient-clinician partnerships, incentives aligned for value and a leadership-instilled culture of learning (IOM 2013). Although much policy research and commentary has focused on informatics and incentives, relatively less has focused on the critical question of creating a culture of learning in these systems. And although its source is debated, most management gurus agree with the adage that "culture eats strategy for breakfast" (Cave 2017), which is why a focus on the cultural dimension is critically important. Some scholars have recognized the important role of human capital - and of front-line clinicians in particular - in the LHS (Verma and Bhatia 2016). In addition to clinicians, doctorally prepared individuals, such as those with a PhD in health services and policy research (HSPR) and fields such as health economics, epidemiology and health informatics, have the potential to make significant contributions to LHSs and health system reform (Bornstein 2016; Brown and Nuti 2016; CIHR-IHSPR 2016). But having a PhD in these fields is not the same as being prepared to support progress toward an LHS. As argued in other papers, substantial change in doctoral training is needed so that graduates can contribute to their full potential and help drive real innovation within the health system (Bornstein 2016; CIHR-IHSPR 2016; Reid 2016).

Training for Health System Improvement: Emerging Lessons from Canadian and US Approaches to Embedded Fellowships.

The benefits of supporting experiential learning for improved health and societal outcomes have been recognized in many countries. A number of funding organizations have developed competitive funding opportunities to support experiential learning in health system organizations outside of the traditional university setting. AcademyHealth in the US is an early innovator that pioneered the Delivery System Science Fellowship (DSSF) and inspired Canada's creation of the Health System Impact (HSI) Fellowship program. The DSSF and HSI Fellowship have similar objectives: to improve the career readiness of doctorally prepared graduates and to build research capacity within health system organizations. However, the programs have taken different approaches to achieve these objectives and operate in different healthcare systems. This paper outlines the two models of embedded fellowships, analyzes their commonalities and differences, discusses lessons learned and suggests future directions for health services and policy research training.

Developing Competencies for Health System Impact: Early Lessons Learned from the Health System Impact Fellows.

BACKGROUND: The Health System Impact (HSI) Fellowship program provides highly qualified post-doctoral fellows studying health services and policy research (HSPR) with opportunities for experiential learning, enriched core competency development and mentorship from senior-level leaders within health system organizations. Its overall aim is to prepare post-doctoral fellows with the research and professional skills, experiences and networks to make meaningful and impactful contributions in careers in academic and applied health system settings. OBJECTIVE: This study examined whether this HSI Fellowship program has contributed to the development of enriched core competencies in HSPR. METHODS: A competency assessment tool was developed and administered to the 46 fellows and their health system and academic supervisors from the inaugural HSI Fellowship cohort. Fellows' self-assessments at baseline, three months and 12 months were analyzed, along with supervisors' assessments at three and 12 months. Descriptive analyses were used to examine competency development over time. Differences by gender and between supervisor and fellow ratings were analyzed. RESULTS: HSI fellows' self-assessments indicate that they strengthened their skills in all 10 enriched core competencies. Supervisors' assessments of the fellows' competencies also improved from baseline to 12 months. Gender differences at baseline disappeared by the 12-month assessment. CONCLUSION: The HSI Fellowship provides an opportunity to develop the full suite of enriched core competencies, particularly in competency domains that are not currently emphasized in HSPR doctoral curriculum.