Selecting physician leaders for clinical service lines: critical success factors.

PURPOSE: Clinical service lines and interdisciplinary centers have emerged as important strategic programs within academic health centers (AHCs). Effective physician leadership is significant to their success, but how these leaders are chosen has not been well studied. The authors conducted a study to identify current models for selecting the physician leaders of clinical service lines, determine critical success factors, and learn how the search process affected service line performance. METHOD: In 2003 and 2004, the authors interviewed clinical and executive personnel involved in 14 programs to establish, or consider establishing, heart or cancer service lines, at 13 AHCs. The responses were coded to identify and analyze trends and themes. RESULTS: The key findings of the survey were (1) the goals and expectations that AHCs set for their service line leaders vary greatly, depending on both the strategic purpose of the service line in the AHC and the service line's stage of development, (2) the matrix organizational structure employed by most AHCs limits the leader's authority over necessary resources, and calls forth a variety of compensating strategies if the service line is to succeed, (3) the AHCs studied used relatively informal processes to identify, evaluate, and select service line leaders, and (4) the leader's job is vitally shaped by the AHC's strategic, structural, and political context, and selection criteria should be determined accordingly. CONCLUSIONS: Institutions should be explicit about the strategic purpose and stage of development of their clinical service lines and be clear about their expectations and requirements in hiring service line leaders.     

How do academic health centers value and encourage clinical research?

To investigate whether there is a misalignment of the perceived values of and incentives for clinical research within U.S. academic health centers (AHCs), in 1999 the authors surveyed medical school deans, academic administrators, department chairs, and faculty members at 80 AHCs that are the members of the University HealthSystem Consortium, a not-for-profit consortium of AHCs. A total of 358 faculty from 58% of the institutions surveyed responded, with a mean of 3.76 responses/institution. There was general agreement that clinical research offers AHCs a considerable spectrum of benefits, including prestige, recruitment and retention of faculty, criteria for promotion of faculty, and financial support. Investigator-initiated research and government-funded research ranked highest in terms of their desirability compared with industry-sponsored and contract research. This preference was agreed upon across all categories of respondents and types of research (translational, clinical tests, and outcomes). Significant differences existed between the perceptions of deans/AHC administrators, who stated that they were increasing their emphasis on clinical investigation in the areas of research space (56% of responders), administrative support (81%), and patient recruitment (61%) and the perceptions of their departmental chairs/faculties in the same areas (34%, 52%, and 40%, respectively; p <.05). Faculty opinions documented few new investments in the actual infrastructure dedicated to clinical research. The authors conclude that their findings, which they consider reasonably representative, strongly suggest that the value of clinical research to AHCs is well understood. Their findings also identify important opportunities for AHCs to provide a wider range of incentives for the conduct of clinical research.     

Adapting industry-style business model to academia in a system of Performance-based Incentive Compensation.

Performance-Based Incentive Compensation (PBIC) plans currently prevail throughout industry and have repeatedly demonstrated effectiveness as powerful motivational tools for attracting and retaining top talent, enhancing key indicators, increasing employee productivity, and, ultimately, enhancing mission-based parameters. The University of Arkansas for Medical Sciences (UAMS) College of Medicine introduced its PBIC plan to further the transition of the college to a high-performing academic and clinical enterprise. A forward-thinking compensation plan was progressively implemented during a three-year period.After the introduction of an aggressive five-year vision plan in 2002, the college introduced a PBIC plan designed to ensure the retention and recruitment of high-quality faculty through the use of uncapped salaries that reflect each faculty member's clinical, research, and education duties. The PBIC plan was introduced with broad, schoolwide principles adaptable to each department and purposely flexible to allow for tailor-made algorithms to fit the specific approaches required by individual departments.As of July 2006, the college had begun to reap a variety of short-term benefits from Phase I of its PBIC program, including increases in revenue and faculty salaries, and increased faculty morale and satisfaction.Successful implementation of a PBIC plan depends on a host of factors, including the development of a process for evaluating performance that is considered fair and reliable to the entire faculty. The college has become more efficient and effective by adopting such a program, which has helped it to increase overall productivity. The PBIC program continues to challenge our faculty members to attain their highest potential while rewarding them accordingly.     

Empowering junior faculty: Penn State's faculty development and mentoring program.

Empowerment of faculty is essential for academic success. The Junior Faculty Development Program (JFDP), sponsored by the Office of Professional Development of the Penn State College of Medicine, was established in 2003 with the goal of promoting the development and advancement of junior faculty so they can achieve success in their academic careers. The program consists of two components: a curriculum in research, education, clinical practice, and career development, and an individual project completed under the guidance of a senior faculty mentor. The curriculum provides faculty with knowledge, skills, and resources. Mentoring provides relationships and support. Together, these elements combine to empower junior faculty to better manage their careers.The effectiveness of the program has been demonstrated by several measures: participants evaluated the program highly, demonstrated increases in their perceptions of their own abilities, and completed tasks important to the advancement of their careers. Participants stated they were better prepared to advance their academic careers and that the individual projects would contribute to their career advancement.On the basis of this experience, the authors suggest that faculty development programs should empower faculty so that they can more effectively chart a successful career in academic medicine. This report describes an empowerment model, and the design, implementation, and evaluation of the Junior Faculty Development Program in 2003-04 and 2004-05. The authors offer this program as a model for the benefit of other institutions and for one of their most valuable assets: junior faculty.     

Physician leadership: enhancing the career development of academic physician administrators and leaders.

As the health care environment grows more complex, there is greater opportunity for physician administrative and management leadership. Although physicians in general, and academic physicians in particular, view management as outside their purview, the increased importance of physician administrative leadership represents an opportunity for academic physicians interested in working at the interface of clinical medicine, health care, finance, and management. These physicians are called academic physician administrators and leaders (APALs). APALs are clinician-administrators whose academic contributions include both scholarly work related to their administrative duties and administrative leadership of academically important programs. However, existing academic career development infrastructure, such as academic promotions, is oriented toward traditional clinician-educator and clinician-researcher faculty. The APAL career path differs from traditional academic pathways because APALs require unique skills, different mentors, and a more expansive definition of academic productivity. This article describes how academic medical institutions could enhance the career development of academic physicians in administrative and leadership positions.     

The legal context for evaluating and dismissing medical students and residents

Medical school faculty often cite the fear of litigation as a reason for their reluctance to offer candid evaluations of students' and residents' performances and to dismiss them when necessary. This article is written to reassure faculty that they have nothing to fear from the courts and that they should uphold high academic standards. Three legal issues of concern to faculty are addressed: What does fair and equitable treatment entail? What are the due process requirements for academic dismissals? Are negative performance evaluations libelous and defamatory? Recommendations are made to meet legal requirements and to promote academic excellence.     

Forces affecting community involvement of AHCs: perspectives of institutional and faculty leaders.

PURPOSE: To understand the external and internal factors that either facilitated or were barriers to an academic health center's (AHC's) involvement in community-based education, research, and clinical care; community service; and community or economic development activities. METHOD: Eight AHCs in the United States were selected by objective criteria for their significant community involvement. Chief executive officers, vice chancellors, deans, and the individuals responsible for community-based education, research, and community service responded to written surveys. Responses were subjected to quantitative and qualitative analyses. RESULTS: The overall response rate was 79% (n = 91). Public perception, an increased focus on a population health perspective, and an increased call for AHCs to be accountable to local and statewide constituents were cited as the most significant external factors contributing to an AHC's community involvement. Institutional leadership, familiarity with community-based organizations, institutional climate, faculty and student interest, and institutional structures were cited as the most significant internal facilitators of community involvement. Fiscal concerns, competition for community-based training sites, lack of collaboration across health professions schools, and inadequate faculty roles and rewards were viewed as the most significant barriers to community involvement. All respondents reported that their AHCs' orientations towards community service, and community-based teaching, research, and clinical care would increase in the next five years. CONCLUSION: Development of a strategic plan may increase the effectiveness of an institution's community involvement. Central to this plan should be a restructuring of faculty roles and reward polices and an increase in faculty release time to promote community involvement. The importance of involving the community in the planning and implementation of community-campus partnerships should not be underestimated.     

The advisory dean program: a personalized approach to academic and career advising for medical students.

Advising and mentoring programs for medical students vary in their official names, scope, and structures. Catalyzed by negative student feedback regarding career advising and a perceived disconnection between faculty and students, in academic year 2003-2004, Columbia University College of Physicians and Surgeons implemented its formal Advisory Dean (AD) Program and disbanded its former advising system that used faculty volunteers. The AD Program has become a key element for enhancing the students' professional development throughout their student training, focusing on topics including, but not limited to, career counseling, professionalism, humanism, and wellness resources. Advisory deans and the dean for student affairs, familiar with resources for academic development, student support, and extracurricular activities, operate at the nexus of the program, providing personalized mentoring and advising for each student. Fully supported by administration and faculty, the program has shown early success according to student feedback. Early feedback from the Class of 2006, who had been involved in our AD Program for three years, has been encouraging. Out of 152 students, 104 (68%) provided feedback, with 93 (89%) of the respondents reporting the AD Program as a valuable initiative. Expecting to further improve on this early positive response, the AD Program will continue to foster an environment conducive to a seamless transition from student to physician.     

A roadmap for academic health centers to establish good laboratory practice-compliant infrastructure

Prior to human clinical trials, nonclinical safety and toxicology studies are required to demonstrate that a new product appears safe for human testing; these nonclinical studies are governed by good laboratory practice (GLP) regulations. As academic health centers (AHCs) embrace the charge to increase the translation of basic science research into clinical discoveries, researchers at these institutions increasingly will be conducting GLP-regulated nonclinical studies. Because the consequences for noncompliance are severe and many AHC researchers are unfamiliar with Food and Drug Administration regulations, the authors describe the regulatory requirements for conducting GLP research, including the strict documentation requirements, the necessary personnel training, the importance of study monitoring, and the critical role that compliance oversight plays in the process. They then explain the process that AHCs interested in conducting GLP studies should take before the start of their research program, including conducting a needs assessment and a gap analysis and selecting a model for GLP compliance. Finally, the authors identify and analyze several critical barriers to developing and implementing a GLP-compliant infrastructure at an AHC. Despite these challenges, the capacity to perform such research will help AHCs to build and maintain competitive research programs and to facilitate the successful translation of faculty-initiated research from nonclinical studies to first-in-human clinical trials.     

Effects of performance-based compensation and faculty track on the clinical activity, research portfolio, and teaching mission of a large academic department of medicine.

PURPOSE: Academic departments of medicine must compete effectively for extramural research support and access to patients while preserving their teaching mission. There is not much literature describing plausible mechanisms for ensuring success. The authors describe the design, implementation, and testing of a performance-based compensation plan in a department of medicine that is closely linked to the faculty appointment track. METHOD: Over a three-year period, the changes this plan effected in research portfolio, clinical enterprise, and faculty satisfaction as well as the teaching perceptions of students and housestaff were measured. RESULTS: The compound annual growth rate (CAGR) for clinical work grew 40% faster after plan implementation. Federal funding increased at a CAGR that was 170% greater than before. The department halved its award rankings at the National Institutes of Health and faculty satisfaction improved compared with the former method of compensation. Faculty who better understood the plan were more satisfied with the conversion. High measures of teaching quality were maintained by faculty with no apparent change in satisfaction among students or housestaff. CONCLUSIONS: This performance-based compensation plan with its emphasis on the objectives of career orientation and faculty track assignment strengthened the opportunity to grow both clinical productivity and the funded research portfolio.     

Three strategies used by academic health centers to expand primary care capacity.

The growth of managed care in the late 1980s and early 1990s severely disadvantaged academic health centers (AHCs). The reliance on primary care gatekeeping and selective contracting by managed care plans were two contributing factors. Because most AHCs had only a modest primary care capacity, they were understandably concerned about their strategic positions. Thus, many felt it was essential to expand their primary care capacities to ensure downstream referrals, to improve contract negotiations with third parties, and to permit assumption of risk for defined populations. Among the different approaches used, three principal strategies emerged for the expansion of the primary care capacity of AHCs: (1) the "assembly strategy," in which many AHCs recruited new generalist faculty into existing clinical departments; (2) the "acquisition strategy," in which AHCs purchased established primary care practices in the community; and (3) the "affiliation strategy," in which some AHCs affiliated with primary care physicians in the community and formed networks of academic and community physicians. For each of these approaches, the author reviews the relative merits and disadvantages, and analyzes why some AHCs' original assumptions about the imperative for increasing primary care capacity may have been spurious. He concludes that recent marketplace and regulatory changes may make it less necessary for AHCs to secure substantial primary care bases in the future.     

Electronic medical record systems at academic health centers: advantages and implementation issues.

The growth of managed care has fueled expectations for a more coordinated delivery of clinical services and a reduction of unnecessary utilization. Among the most important issues that constrain these expectations is the transfer of medical information. Electronic medical record (EMR) systems appear to offer substantive advantages over paper records for both containing costs and improving the quality of care. However, incorporation of EMR systems into practice settings has languished. Among the barriers to implementation are software problems of codification and entry of data, security issues, a dearth of integrated delivery systems, reluctant providers, and prohibitive costs. The training programs of academic health centers (AHCs) are optimal environments for testing and implementing EMR systems. AHCs have the expertise to resolve remaining software issues, the components necessary for integrated delivery, a culture for innovation in clinical practice, and a generation of future providers that can be acclimated to the requisites for computerized records. The authors critically review these and other issues of implementing EMR systems at AHCs and propose four necessary steps for financing their implementation.     

Should U.S. academic health centers play a leadership role in global health initiatives? Observations from three years in China.

Based on his work in Shanghai, China, the author believes that U.S. academic health centers (AHCs) should take a leadership role in global health initiatives. While acknowledging that most AHCs already have focused projects involving research or education with foreign institutions, he proposes a greater coordination of these projects into programs that, in some areas, could also be linked to clinical delivery systems where care may be provided. These AHC "platforms" overseas would be structured as a partnership between an AHC in the United States and one in the foreign country where the platform is located, to promote their missions of education, research, and service. For example, U.S. AHCs benefit, and are often dependent upon, international trainees who seek further clinical or research training in the United States. However, the identification of suitable candidates and career guidance, so the students' career choices could benefit their home countries, are often lacking. Thus, the United States is often viewed as facilitating a "brain drain" of future leaders in academic medicine from developing areas of the world. The author proposes a way to lessen this problem by shifting more on-site training to settings in the students' home countries, which could occur if AHCs were willing to develop overseas platforms. U.S. students would also benefit from access to medical training in foreign lands for both the cultural perspectives they offer and the unique diseases and medical situations encountered. He also suggests that shared platforms would lead to greater research opportunities for institutions in the United States and abroad. He argues for increased efforts at coordinating these activities with the rising demand for Western clinical services by multinational companies and U.S. expatriate communities overseas. The potential pitfalls of such initiatives as well as the need for permanent relationships are discussed. In conclusion, he believes that AHCs have an opportunity to establish global health initiatives through education, research, and patient care that will both enhance their own institutions and benefit the international community.     

Mission-based budgeting: removing a graveyard.

Many activities in today's medical schools no longer have medical students' education as their central reason for existence. Faculty are hired primarily to provide clinical service or to make discoveries, with the role of educator of secondary importance. Budgeting in medical schools has not evolved in concert with these changing roles of faculty. The cost of medical students' education is still calculated as if all faculty were hired primarily to teach medical students and their other activities were to support this "central" mission. Most medical schools still mix revenues without regard to intent and cannot accurately determine costs because they confuse expenses with costs. At the University of Florida College of Medicine, a group of administrators, chairpersons, and faculty developed a budgeting process now called mission-based budgeting. This is a three-step process: (1) revenues are prospectively identified for each mission and then aligned with intended purposes; (2) faculty productivity, i.e., faculty effort and its quality, is measured for each of the missions; and (3) productivity is linked to the prospective budget for each mission. This process allows the institution to understand the intent of its revenues, to measure how productive its faculty are, to learn the true costs of its missions, to make wise investment decisions (subsidies), and to justify to various constituents its use of revenues. The authors describe this process, focusing particularly on methods used to develop a comprehensive database for assessment of faculty productivity in education.     

PhD faculty in clinical departments of U.S. medical schools, 1981-1999: their widening presence and roles in research.

PURPOSE: To analyze the growth, research activities, and academic status of PhD faculty in U. S. medical school clinical departments between 1981 and 1999. METHOD: Full-time U.S. medical school faculty who had PhDs and appointments in clinical departments in 1981 and 1999 and junior PhD faculty who became assistant professors between 1981 and 1990 were selected from the Faculty Roster System of the Association of American Medical Colleges. Their research activities and academic statuses were compared with those of MD or MD/PhD faculty in clinical departments or PhD faculty in basic science departments in the same years. RESULTS: The number of PhD faculty in clinical departments now exceeds the number of PhD faculty in basic science departments. PhD faculty in clinical departments come from diverse research backgrounds, contribute substantially to the research intensity of their institutions, and are more likely than their counterparts in basic science departments to become involved in research involving human participants or human tissues. PhD faculty in clinical departments are less likely than their counterparts in basic science departments, but are as likely as physicians in clinical departments, to be rewarded with academic promotion. They are less likely than their physician colleagues to be promoted in research-intensive departments such as departments of medicine and at top 20 research-intensive schools. CONCLUSIONS: The burgeoning career opportunities for PhD faculty in clinical departments should be reflected in the course work, mentorship, and potential thesis topics of PhD training programs. In lieu of tenure, research-intensive medical schools should develop alternative career tracks providing somewhat greater job stability for these faculty.     

Building a transcontinental affiliation: a new model for academic health centers.

The recent affiliation of The Methodist Hospital (TMH) with Weill Medical College (WMC) of Cornell University and NewYork-Presbyterian Hospital is the first transcontinental primary affiliation between major, not-for-profit academic health centers (AHCs) in the United States. The authors describe the process followed, the issues involved, the initial accomplishments, and the opportunities envisioned. The key enablers of this affiliation were a rapid process, mutual trust based on existing professional relationships, and commitment to the project by Board leadership. Because of their geographic separation, the parties were not competitors in providing clinical care to their regional populations. The affiliation is nonexclusive, but is reciprocally primary in New York and Texas. Members of the TMH medical staff are eligible for faculty appointments at WMC. The principal areas of collaboration will be education, research, quality improvement, information technology, and international program development. The principal challenge has been the physical distance between the parties. Although extensive use of videoconferencing has been successful, personal contact is essential in establishing relationships. External processes impose a slower sequence and tempo of events than some might wish. This new model for AHCs creates exciting possibilities for the tripartite mission of research, education, and patient care. Realizing the potential of these opportunities will require unconstrained ideas and substantial investment of time and other critical resources. Since many consider that AHCs are in economic and cultural crisis, successful development of such possibilities could have importance beyond the collective interests of these three institutions.     

Recognizing clinical faculty's contributions in education.

OBJECTIVE: A faculty productivity profile system was designed to recognize faculty's contributions to administrative, educational, and research activities. It has long been recognized that clinical faculty receive little recognition or compensation for their efforts in education. Our surgery department previously had in place a recognition program for research achievements, but not for educational contributions. The new system was designed to recognize and reward all aspects of faculty contributions, including education. DESCRIPTION: The faculty productivity profile is a simple Excel document sent to each faculty member once a year. We piloted the program for the first time in 2001, recognizing faculty's contributions for the previous year. The pilot began with the formation of a committee whose first function was to identify all possible opportunities for faculty to participate as educators at our institution. This included giving lectures, participating in faculty development programs, serving as mentors, interviewing student or resident candidates, serving in administrative educational roles (e.g., clerkship or residency director), giving oral exams, or attending conferences and journal club. The committee then developed a point scale assigning each activity or contribution a value on a scale of 0-25. Each activity was then listed on the Excel form. Faculty were to fill in the number of times each activity was performed and this was multiplied by the points to obtain a weighted value. Point values for conferences were determined by percentage of conferences attended for a year (i.e., for grand rounds, those attending 0-49%, 50-75%, 75-90%, and more than 90% received 0, 20, 40, and 60 points, respectively). Points were also assigned for teaching awards and high scores on student and resident evaluations. After approval by the committee and the department chairman, the form was presented at a faculty meeting. Each faculty member then received a floppy disk with the form and was asked to complete the form and attach a supporting copy of his or her CV. The form required only input of numbers or a "yes" or "no." After submission, the clerkship coordinator input additional data from a database of conference attendance and student evaluations. Points were then calculated for each faculty member based upon his or her contributions and each activity's weighted value. A dinner was held to recognize outstanding faculty contributions. All faculty completing the form were invited and recognized and those with outstanding contributions received awards. DISCUSSION: Teaching medical students and residents is a rewarding experience; however, it requires significant time and effort. Faculty who feel their contributions are unrecognized may be more likely to burn out and less likely to continue contributing. We believe it is worthwhile to recognize faculty contributions in all areas, including education. Our pilot program had excellent participation due to the ease of using the form. We believe it has improved faculty morale and willingness to participate. We are continuing the program and plan to evaluate its impact on encouraging continued participation in teaching.     

Integrating educational objectives and the evaluation process in a general surgery residency program.

Although the Accreditation Council for Graduate Medical Education (ACGME) requires that all of its approved residency programs have written goals and objectives and an evaluation process, many programs have difficulty achieving these goals. For eight years, the general surgery residency program at Abington Memorial Hospital has used a system that integrates each rotation's cognitive, clinical, and procedural objectives into the faculty's evaluation of residents and residents' evaluation of the rotation. The integration of goals and objectives with the post-rotation evaluations provides the program with an ongoing and continual assessment of each resident's progress, the effectiveness of the faculty as teachers, and the educational value of each rotation. In this essay, the authors describe this integrated system and provide examples of one rotation's goals and objectives and the evaluation forms used by faculty and residents.     

Lessons learned from a distance-based consulting program to assist faculty development projects.

Changes in faculty roles and demographics necessitate a re-examination of the types of professional development opportunities offered in academic institutions. A distance-based consulting program was designed to assist faculty development projects as they progress through all stages of faculty development: needs assessment, project design, implementation, and, in particular, program evaluation and dissemination of results (i.e., presentations and published articles). The progress of 17 faculty development projects in primary care educational sites that received assistance in the United States and Canada was tracked over two years. Three factors were identified as having the most impact on the success of faculty development projects: (1) funds committed to and designated for faculty development; (2) funded, protected time for at least one person to implement the faculty development initiative; and (3) an environment capable of supporting faculty development initiatives (e.g., no major budget shortfall, few faculty transitions, a strong mission, no threat of mergers). Only a few of the participating sites reached the stage of evaluating and publishing articles about the outcomes of their projects within the designated 15-month time frame, with many sites reporting environmental impediments to project success. The authors describe the institutional characteristics that facilitated project success, assess the usefulness of distance-based consulting efforts, and offer recommendations for future distance-based consulting programs. They conclude by noting that the personal touch (i.e., one-on-one contact with consultants) is what is most appreciated, and that excellent one-on-one, in-person assistance may be inherently more effective than even the best-run distance-based consulting.     

Faculty Publication Rates and the Science–Practice Divide in Clinical Psychology

This commentary points out serious areas for concern in the assessment of faculty productivity as reported by Stewart, Roberts, and Roy (2007). Matters of measurement are especially problematic when ranking subjects rather than calculating group trends or testing the relationships among variables. Beyond measurement issues are broader questions about the value of using faculty publication counts to assess clinical psychology programs. An alternate and perhaps more meaningful approach to program quality could focus on student outcomes rather than faculty outcomes, and clinical and scientific measures of quality.