Implementing a simpler approach to mission-based planning in a medical school.

Changes in the education, research, and health care environments have had a major impact on the way in which medical schools fulfill their missions, and mission-based management approaches have been suggested to link the financial information of mission costs and revenues with measures of mission activity and productivity. The authors describe a simpler system, termed Mission-Aligned Planning (MAP), and its development and implementation, during fiscal years 2002 and 2003, at the School of Medicine at the University of Texas Health Science Center at San Antonio, Texas. The MAP system merges financial measures and activity measures to allow a broad understanding of the mission activities, to facilitate strategic planning at the school and departmental levels. During the two fiscal years mentioned above, faculty of the school of medicine reported their annual hours spent in the four missions of teaching, research, clinical care, and administration and service in a survey designed by the faculty. A financial profit or loss in each mission was determined for each department by allocation of all departmental expenses and revenues to each mission. Faculty expenses (and related expenses) were allocated to the missions based on the percentage of faculty effort in each mission. This information was correlated with objective measures of mission activities. The assessment of activity allowed a better understanding of the real costs of mission activities by linking salary costs, assumed to be related to faculty time, to the missions. This was a basis for strategic planning and for allocation of institutional resources.     

Rediscovering the medical school.

Medical schools, once devoted primarily to educating medical students, have evolved into complex academic medical centers (AMCs), some of which place a greater emphasis on research and the clinical business than on educating future physicians. This occurred primarily as the result of outside forces, specifically the available revenue streams that have fostered growth. Discipline-based departments have been at the center of the governance structure of medical schools, but many AMCs now have research institutes and centers to enhance research productivity, and faculty group practices to maximize clinical revenue. Although AMCs have been successful in making scientific discoveries, developing new technologies, and providing state-of-the-art clinical care, their successes have not always been favorable to the education mission. Furthermore, the roles of departments and their chairs have not always been carefully considered; a mismatch between organizational and governance structures is occurring. In this article several suggestions are offered to help medical schools rediscover their unique reason for existence and better distinguish core missions from core businesses. Mission-based management and mission-based budgeting provide the framework for maximum success of all the missions. Specific suggestions include (1) organizing a national task force to consider optimal organizational and governance structures of modern AMCs, (2) establishing a core teaching faculty, (3) creating a matrix letter of assignment that aligns salary rates with assigned activities, (4) linking education to the provision of health care to the underinsured, and (5) forming education centers to effectively centralize governance of the education mission.     

The academy movement: a structural approach to reinvigorating the educational mission.

Despite its fundamental importance, the educational mission of most medical schools receives far less recognition and support than do the missions of research and patient care. This disparity is based, in part, on the predominance of discipline-based departments, which focus on the more sustainable enterprises of research and patient care. Where departmental teaching is emphasized, it tends to center on trainees directly associated with the department-leaving medical students unsupported. The authors argue that the ongoing erosion of the educational mission will never be reversed unless there are changes in the underlying structure of medical schools. Academies of medical educators are developing at a number of medical schools to advance the school-wide mission of education. The authors describe and compare key features of such organizations at eight medical schools, identified through an informal survey of the Society of Directors of Research in Medical Education, along with direct contacts with specific schools. Although these entities are relatively new, initial assessments suggest that they have already had a major impact on the recognition of teaching efforts by the faculty, fueled curricular reform, promoted educational scholarship, and garnered new resources to support teaching. The academy movement, as a structural approach to change, shows promise for reinvigorating the educational mission of academic medicine.     

Overcoming a perfect storm: an academic cardiology section's story of survival.

Increasingly, academic institutions are grappling with financial pressures that threaten the academic mission. The author presents an actual case history in which a section of cardiology in an academic health center was confronted with huge projected deficits that had to be eliminated within the fiscal year. The section used eight principles to shift from deficit to profitability (i.e., having revenue exceed costs). These principles included confronting the brutal facts, managing costs and revenue cycles, setting expectations for faculty, and quality improvement. The section accomplished deficit reduction through reducing faculty salaries (nearly $2 million) and nonfaculty salaries ($1.3 million) and reducing operational costs while maintaining revenues by increasing individual faculty productivity and reducing accounts receivable. In the face of these reductions, clinical revenues were maintained, but research revenue and productivity fell (but research is being fostered now that clinical services are profitable again). These principles can be used to stabilize the financial position of clinical practices in academic settings that are facing financial challenges.     

Working across the boundaries of health professions disciplines in education, research, and service: the University of Washington experience.

The Institute of Medicine's vision for health professions education specifies working together across professions and schools to provide patient-centered care. Improvement in collaborative preparation of health professionals is seen as central to achieving substantial improvement in the quality of health care. In this article, the authors address one central question: How can medical schools work with other health-sciences schools to promote their educational, research, and service missions? The authors summarize the history of the University of Washington (UW) Health Sciences Center in promoting interprofessional collaboration in education, service and research; analyze the key strategic, structural, cultural and technical elements that have promoted success or served as barriers in the development of the UW Center for Health Sciences Interprofessional Education and Research; and suggest strategies that may be transferable to other institutions seeking to implement an interprofessional health sciences program. These include both top-down and bottom-up authority and function in key working groups, institutional policies such as interprofessional course numbers and shared indirect costs, and development of a culture of interprofessionalism among faculty and students across program boundaries.     

Measuring faculty effort and contributions in medical education.

A national panel on medical education was appointed as a component of the AAMC's Mission-based Management Program and charged with developing a metrics system for measuring medical school faculty effort and contributions to a school's education mission. The panel first defined important variables to be considered in creating such a system: the education programs in which medical school faculty participate; the categories of education work that may be performed in each program (teaching, development of education products, administration and service, and scholarship in education); and the array of specific education activities that faculty could perform in each of these work areas. The panel based the system on a relative value scale, since this approach does not equate faculty performance solely to the time expended by a faculty member in pursuit of a specific activity. Also, a four-step process to create relative value units (RVUs) for education activities was developed. This process incorporates quantitative and qualitative measures of faculty activity and also can measure and value the distribution of faculty effort relative to a school's education mission. When adapted to the education mission and culture of an individual school, the proposed metrics system can provide critical information that will assist the school's leadership in evaluating and rewarding faculty performance in education and will support a mission-based management strategy in the school.     

How do medical schools use measurement systems to track faculty activity and productivity in teaching?

The authors describe their findings from a study that (1) identified 41 medical schools or medical school departments that used metric systems to quantify faculty activity and productivity in teaching and (2) analyzed the purposes and progress of those systems. Among the reasons articulated for developing these systems, the most common was to identify a "rational" method for distributing funds to departments. More generally, institutions wanted to emphasize the importance of the school's educational mission. The schools varied in the types of information they tracked, ranging from a selective focus on medical school education to a comprehensive assessment of teaching activity and educational administration, committee work, and advising. Schools were almost evenly split between those that used a relative-value-unit method of tracking activity and those that used a contact-hour method. This study also identified six challenges that the institutions encountered with these metric systems: (1) the lack of a culture of data in management; (2) skepticism of faculty and chairs; (3) the misguided search for one perfect metric; (4) the expectation that a metric system will erase ambiguity regarding faculty teaching contributions; (5) the lack of, and difficulty with developing, measures of quality; and (6) the tendency to become overly complex. Because of the concern about the teaching mission at medical schools, the number of institutions developing educational metric systems will likely increase in the coming years. By documenting and accounting financially for teaching, medical schools can ensure that the educational mission is valued and appropriately supported.     

Survival and recovery: maintaining the educational mission of the Louisiana state university school of medicine in the aftermath of hurricane Katrina.

Hurricane Katrina devastated New Orleans and the coastlines of Louisiana, Mississippi, and Alabama on August 29, 2005. The flooding in New Orleans left hundreds of thousands of people homeless and threatened to close businesses and institutions, including Louisiana State University (LSU) School of Medicine and its two principle training sites in New Orleans, Charity Hospital and University Hospital. In the weeks immediately after the storm, LSU School of Medicine resumed undergraduate and graduate medical education in Baton Rouge, Louisiana and elsewhere. The authors discuss the specific challenges they faced in relocating administrative operations, maintaining the mission of medical education, and dealing with the displacement of faculty, staff, residents, students, and patients, and the processes used to overcome these challenges. They focus on the school's educational missions, but challenges faced by the offices of student affairs, faculty affairs, and admissions are also discussed. LSU School of Medicine's experience provides lessons about organizational preparedness for a mass disaster that may be of interest to other medical schools.     

Administrative relationships between medical schools and community preceptors.

PURPOSE: To determine the current administrative relationships between medical schools and community preceptors, with special emphasis on arrangements for academic appointment, review, and promotion. METHOD: In 1999, administrative contacts at all 126 U.S. allopathic medical schools were mailed a ten-item questionnaire to elicit information concerning the current practices of the schools regarding community preceptors, who were defined as volunteer or part-time physician faculty, primarily practicing at non-university-owned facilities, who contribute to medical students' and/or residents' education in various specified ways. RESULTS: Responses were received from 71 (56%) of the schools; they were in general a representative sample of U.S. medical schools. The numbers of preceptors per school ranged from 40 to 3,500. Sixty-seven percent of reporting schools identified clinical departments as the main administrative interface with preceptors. Only three schools used a central office; none exclusively used a regionalized system. Forty-four schools (63.8%) reported using formal written criteria for all preceptor appointments. Sixty-six schools (93%) used consistent academic titling systems, with 83.3% using titles including the word "clinical." Thirty-three schools (47.8%) reported that their departments conducted regular preceptor reviews; an additional 28 reported reviews by some departments. Preceptors were eligible for promotion at 94.4% of the responding schools. At 46.8%, specific promotion criteria exist; four schools were developing such criteria. Preceptors' interest in academic promotion was perceived to be moderate or low. CONCLUSION: A substantial proportion of U.S. medical schools have taken action to recognize preceptors as a unique faculty group. The comments received indicate that this is an active area of development in faculty affairs policy.     

A mission-based reporting system applied to an academic pathology department

We report how data from the University of California (UC) Davis mission-based reporting system (MBR) can be used to define contributions for each division within a Department of Pathology based on faculty rank and series, and to evaluate whether these contributions are in alignment with the missions of the department and the goals of the school's leadership. MBR summary reports were generated for each division within the Department of Pathology; these reports illustrated the average contribution for each faculty rank and series in each of the following missions: investigative/creative work (research), teaching, clinical service, and administrative/community service. All divisions contributed equally to the teaching mission, averaging approximately 1/3 of a faculty member's time. Research was the primary mission for faculty in both the Research and the Clinical Pathology divisions, whereas clinical service was the primary mission for Anatomic Pathology. Both Anatomic Pathology and Clinical Pathology also played a large role in the administration/community service mission. These roles were appropriate based on the division's distribution of faculty in each of the faculty series. The average contribution to both the research and administrative/community service missions were larger for the Department of Pathology than it was for the school as a whole. The Department of Pathology's average contribution to both the teaching and clinical service missions was less than the school's average. We conclude that MBR data creates unique profiles for divisions and the department and enables interdepartmental comparisons that would not be possible by other means. Within the context of our school, the present analysis illustrates that the Department of Pathology is fulfilling the expectations of the school's leadership. In a more general sense, these profiles allow appropriate monitoring of the workforce, funds flow analysis, allocation of resources, and strategic planning in an academic medical center.     

Creating a mission-based reporting system at an academic health center.

The authors developed a Web-based mission-based reporting (MBR) system for their university's (UC Davis's) health system to report faculty members' activities in research and creative work, clinical service, education, and community/university service. They developed the system over several years (1998-2001) in response to a perceived need to better define faculty members' productivity for faculty development, financial management, and program assessment. The goal was to create a measurement tool that could be used by department chairs to counsel faculty on their performances. The MBR system provides measures of effort for each of the university's four missions. Departments or the school can use the output to better define expenditures and allocations of resources. The system provides both a quantitative metric of times spent on various activities within each mission, and a qualitative metric for the effort expended. The authors report the process of developing the MBR system and making it applicable for both clinical and basic science departments, and the mixed success experienced in its implementation. The system appears to depict the activities of most faculty fairly accurately, and chairs of test departments have been generally enthusiastic. However, resistance to general implementation remains, chiefly due to concerns about reliability, validity, and time required for completing the report. The authors conclude that MBR can be useful but will require some streamlining and the elimination of other redundant reporting instruments. A well-defined purpose is required to motivate its use.     

Financing graduate medical education.

The direct costs of residency training in the United States are over $1 billion per year. These educational programs have been organized predominantly around hospital services and supported by hospital revenues. Pressure has been increasing to reduce the rate of increase in hospital expenditures or costs or both. This article describes alternative methods for financing graduate medical education. Debate over the current sources of financing reveals several troublesome issues: the presence of residents allegedly decreases the productivity of professionals and leads to overusage of ancillary services, proposed methods to pay for faculty salaries and services have created confusion and concern, and the financing of ambulatory-care training has been insufficient and poorly coordinated. The medical-education community must resolve these professional and educational problems so that financing issues can be debated and properly defended.     

Tenure in transition: trends in basic science faculty appointment policies at U.S. medical schools.

This article-based on a 2002 survey of 125 U.S. allopathic medical schools, reviews of institutional policy documents, and interviews with medical school leaders-explores and analyzes three trends in appointment and tenure policies for basic science faculty at U.S. medical schools. First, the percentage of full-time, nontenure track basic science faculty has increased, from 12% in 1980 to 20% in 2000. More dramatically, by the late 1990s, the percentage of new basic science faculty hired on a nontenure track surpassed the percentage hired on a traditional tenure-track line. This development stems from the tendency of some schools to appoint faculty to nontenure-eligible "research scientists" faculty tracks, to hire junior faculty on 100% grant funding, and to allow nontenure-track faculty to switch to the tenure track as their research career progresses. The second trend is an alteration to the tenure financial guarantee. Historically, at most medical schools, it was assumed that tenure guaranteed total institutional salary for basic scientists. Schools have begun to redefine that commitment to less than full salary to protect against financial vulnerabilities and to provide a means to reduce faculty salaries, if warranted. The third trend is increased flexibility to pretenure policies. Schools have lengthened probationary periods, revised up-or-out provisions, instituted stopping-the-tenure-clock policies and less-than-full-time appointments, and permitted faculty to switch between the tenure and nontenure tracks. These policy modifications recognize the increased professional and personal demands on faculty time.     

Using a productivity-based physician compensation program at an academic health center: a case study.

PURPOSE: With increased budget constraints, academic health centers (AHCs) have turned their focus on physician compensation. While many AHCs are concerned that compensation programs driven primarily by revenue generation will have a negative impact on their academic mission, little information is available to support this. The authors examined the effects on teaching and clinical productivity of an innovative compensation program for pediatrics primary care faculty at an AHC and related those effects to national standards for productivity. METHOD: A baseline productivity and compensation assessment was conducted for a group of 35 academic general pediatricians. The data were compared with Medical Group Management Association (MGMA) figures for general pediatricians. A productivity-based faculty compensation program using the work component of the relative-value unit (RVU) as the measure of productivity was designed and implemented. Productivity and compensation were measured after the first year of the program and compared with the baseline assessment. The numbers of hours precepting students and residents and the students' evaluations of their clinical experiences before and after implementation of the program were compared. RESULTS: The baseline assessment showed that over half of the faculty had productivity that fell below the MGMA 25th percentile, while the majority had compensation that exceeded this percentile. After implementation of the compensation program, 89% of the faculty increased their clinical productivity. The times faculty spent precepting and students' evaluations before and after program implementation were unchanged. CONCLUSIONS: Successful productivity-based physician compensation programs can be developed for AHCs.     

The Academy at Harvard Medical School: nurturing teaching and stimulating innovation.

The Academy at Harvard Medical School, established in 2001, was formed at a critical moment for medical schools in this country. Several decades of enormous growth in the biomedical research and clinical care activities of medical school faculty have resulted in great societal benefit. The unintended consequence has been a decline in faculty time and reward for the educational mission that is unique to a medical school. The impact of this decline is particularly felt now because the explosive growth in the science and technology relevant to medical practice, coupled with dramatic changes in the health care delivery system, calls for new models for the education of the next generation of physicians. The mission of the academy is to renew and reinvigorate the educational mission of Harvard Medical School (HMS). By bringing together a select group of some of the school's most talented and dedicated faculty and providing direct support for their work related to education, the academy has created a unique mechanism for increasing the recognition of teaching contributions of both academy members and the teaching faculty at large, fostering educational innovation, and providing a forum for the exchange of ideas related to medical education that cross departmental and institutional lines. The authors describe the academy's membership criteria, structure, governance, activities, institutional impact, and plans for long-term evaluation, and indicate challenges the academy will face in the future.     

Mission aligned management and allocation: a successfully implemented model of mission-based budgeting.

In response to declining funding support and increasing competition, medical schools have developed financial management models to assure that resource allocation supports core mission-related activities. The authors describe the development and implementation of such a model at the University of Wisconsin Medical School. The development occurred in three phases and included consensus building on the need for mission-based budgeting, extensive faculty involvement to create a credible model, and decisions about basic principles for the model. While each school may encounter different constraints and opportunities, the authors outline a series of generic issues that any medical school is likely to face when implementing a mission-based budgeting model. These issues include decisions about the amounts and sources of funds to be used in the budgeting process, whether funds should be allocated at the department or individual faculty level, the specific metrics for measuring academic activities, the relative amounts for research and teaching activities, and how to use the budget process to support new initiatives and strategic priorities. The University of Wisconsin Medical School's Mission Aligned Management and Allocation (MAMA) model was implemented in 1999. The authors discuss implementation issues, including timetable, formulas used to cap budget changes among departments during phase-in, outcome measures used to monitor the effect of the new budget model, and a process for school-wide budget oversight. Finally, they discuss outcomes tracked during two years of full implementation to assess the success of the new MAMA budget process.     

The metrics process: Baylor's development of a "report card" for faculty and departments.

In 1996, Baylor College of Medicine began the first year of its "metrics process," collecting, analyzing, and reporting data on the performance of each individual faculty member and each department in achieving the school's missions of education, patient care, research, service, and finance. This article is a report of the first two years of the process, with updates about the 1999 process, future plans, and lessons learned. The primary goal of the metrics process is to provide meaningful data to assess and improve the performance of faculty and departments across all missions. The authors (1) indicate the categories chosen, within each mission of the school, for measuring faculty time and effort (e.g., patient care, with or without learners) and state the measures chosen (e.g., percentage of time); (2) describe the development of questionnaires in 1996 and 1997 to acquire data from faculty, in the chosen categories and measures, about the time and effort they spent; and (3) report highlights of the resulting departmental data that were gathered in 1997. Among the key categories and units of measure chosen for measuring faculty (and departmental) time and effort are research grant dollars (total and per research full-time equivalent, or FTE); basic research grant dollars per square foot of laboratory space; percentage of faculty who spend at least 50% of their time in research who are National Institutes of Health principal investigators; numbers of inpatient and outpatient visits per evaluation and management FTE; total relative value units (RVUs) per patient-care FTE; patient-care income/RVU and expense/RVU for total faculty and support staff; percentage of faculty with at least one leadership position in a state or national organization; and income in excess of expense, by mission (e.g., patient care). Results of comparing data from the first two years of the metrics process demonstrate marked improvements in performance for most research measures (i.e., items of measurement agreed upon for the metrics process). The process is continually being redeveloped; the ultimate challenge is to place the objective measurements in a context where less objective qualities (e.g., innovation) also figure importantly in the evaluation and fostering of excellence. The metrics process is providing important management data, encouraging significant discussions among faculty and chairs about performance and accountability, and aiding greatly in departmental goal-setting and ultimately in determining the overall performance of the school.     

Implementing the logic model for measuring the value of faculty affairs activities.

In today's environment of increasing accountability in higher education and health care, it is critical that administrative units of a medical school demonstrate the added value of their activities to the school's mission and that these units discriminate those activities that demonstrate the most return on investment. This is particularly important for administrative units whose activities may not be considered essential to the basic functioning of the medical school. For example, admissions would likely be considered an essential administrative unit that the medical school cannot do without, while faculty development might be considered nonessential. Effective measurement systems serve two purposes. They guide decision making throughout the organization and they serve as a basis for evaluating performance. This article describes use of the program logic model to measure the contribution of faculty affairs and development offices to the recruitment, retention, and development of a medical school's teaching faculty, an outcome central to the mission of the medical school. The process of developing and rewarding faculty for teaching is used to illustrate the application of this method in linking activities of faculty affairs and development offices to outcomes that are of importance to the medical school.     

The effects of a changing environment on relationships between medical schools and their parent universities.

Medical schools differ from other university graduate schools in that community settings, hospitals, and ambulatory care facilities are required for medical education, and most of these settings are either owned by or closely affiliated with the university. Thus, the extraordinary changes in recent years in the organization, delivery, and financing of health care have required the attention not only of the leadership of academic medical centers (i.e., medical schools and their owned or closely affiliated teaching hospitals) but also of the administrators and boards of their parent universities. Many university-wide structures and policies that previously served the medical school well in accomplishing these missions may now be viewed as inflexible by the faculty and administration of the school. Conversely, the historically distant governance and administrative oversight of the medical school has become a concern for some at the university, given the huge budgets of the school, its faculty practice, and its affiliated hospital(s). From information derived mainly from annual visits to 14 medical schools from 1996 through June 2000, the authors review the issues between medical schools and their parent universities and the strategies being used to resolve them. These strategies include changes in the governance, organization, and management of the medical school, such as unified authority for health affairs, reengineered administrative systems, and increased autonomy in decision making. The authors conclude that these strategies appear to be working on behalf of not only the medical school but, in some instances, the university at large. They also comment on possible negative implications of the greater separation of the medical school from its parent university.