Implementing a mission-based reporting system at an academic health center: a method for mission enhancement.

PURPOSE: To describe the utility of school-wide use of mission-based reporting (MBR) for medical school deans and department chairs. METHOD: All faculty members in the University of California, Davis, School of Medicine reported their clinical, creative, teaching, and service activities for 2000-2001 to the MBR system. The authors report on school-wide and department MBR profiles, and profiles by rank and academic series. They validate MBR by comparing individual results with actual merit actions reviewed independently by the school's academic personnel committee. RESULTS: A total of 419 faculty members (85%) completed their MBR reports. The average faculty member spent considerably more than 50 hours per week fulfilling the missions of the school, and full professors and faculty members in academic series supported by state funds were the most productive in investigative and creative work. The teaching load was shared equally by all the academic ranks, although the clinician-scholars taught more than did faculty members in the other series. There was an inverse relationship between clinical load and academic rank, with the majority of the clinical work performed by junior faculty members. MBR results compared favorably with the merit review process, although MBR is not expected to replace the traditional peer review system. CONCLUSION: The creation of these graphic profiles and summaries is a valuable feature of MBR that would not have been possible without such quantitative data. The profiles allow monitoring to ensure that workload conforms to established objectives for individuals, departments, academic ranks and series. Finally, the authors discuss future directions for their MBR system.     

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.     

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.     

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.     

The impact of centers and institutes on faculty life: findings from a study of basic science and internal medicine faculty at research-intensive medical schools.

PURPOSE: To examine the impact of organized research centers on faculty productivity and work life for basic science and internal medicine faculty at research-intensive medical schools. METHOD: In 2005, the authors administered a questionnaire to a random stratified sample of full-time faculty in basic science and internal medicine departments at the top 40 research-intensive U.S. medical schools. The survey instrument asked faculty about the extent of their involvement in centers and institutes, the direction and extent of their activities, and their satisfaction with various dimensions of work. RESULTS: A total of 778 faculty members completed the questionnaire (72.0%). Basic science faculty with center affiliations produced more research publications and grants while devoting comparable effort to teaching as their non-center-affiliated peers. These faculty reported greater dissatisfaction in workload and in the mix of their activities. Internal medicine MD center-affiliated faculty were more productive in research activities and spent less effort in patient care and more effort in research than their non-center-affiliated peers. These faculty were more satisfied with promotion, opportunities for research, and the pace of their professional advancement. CONCLUSIONS: Findings indicate that faculty from different departments and with different ranks and backgrounds interact with centers and institutes in multiple ways. For basic science faculty, center involvement appears to be an addition to, not a substitute for, their usual departmental obligations. For internal medicine MD faculty, center involvement appears to serve as an opportunity for protected effort in research away from the demands of clinical practice.     

Current issues facing academic surgery departments: stakeholders' views.

PURPOSE: To determine the issues important to stakeholders in today's academic surgery departments, to query key stakeholders about possible solutions, and to investigate the correlation of organizational alignment among department stakeholders with department performance. METHOD: Between July 2003 and October 2005, the author designed, piloted and carried out a study in which he interviewed key stakeholders-deans, chief executive officers/chief financial officers (CEOs/CFOs) of hospitals and health system practice plans, surgery department chairs, and surgery department members-from 12 randomly selected academic surgery departments. Important issues and solutions were identified and comparisons among stakeholder groups performed. Alignment was evaluated both among and within groups and organizations. RESULTS: Stakeholders (11 deans, 9 CEO/CFOs, 12 department chairs, 10 department faculty members) identified 12 issues and offered potential solutions and responses important to today's academic surgery department. One issue identified was promotion and tenure; nearly all stakeholders stated that its current form needed to be changed. Alignment analysis was incomplete because of inconsistent outcomes reporting. CONCLUSIONS: The uniformity of issues facing academic surgery departments and the similarity of the solutions proposed to address these issues (both study findings) suggest a need to change the paradigm and think "outside the box." The study findings suggest that academic surgery departments, under strong leaders, must establish a unified culture, define a compelling vision, articulate a clear mission, and develop fully accepted values to be successful. The study findings could be useful in designing and developing academic surgery departments in today's health care environment.     

Measuring contributions to the research mission of medical schools.

The authors of this article, who were the members and staff of a research panel formed by the AAMC as part of its mission-based management initiative, reflect on the growing interest in quantitative information in the management of the research mission of medical schools. They note the serious limitations of any such system of measures for research, particularly its inability to represent directly the quality of the research effort. Despite these concerns, the authors acknowledge that leaders in academic medicine have always used quantitative measures in one form or another to compare performance or assess progress. Two factors appear to be driving increases in this practice: (1) the need to demonstrate to institutional stakeholders that resources are being used wisely and that the school's performance justifies continued investment in the research mission; and (2) the need to fashion an economic strategy to manage precious institutional resources, particularly research space. Given these realities, the authors offer guidelines for the proper development and use of measures to assess contributions by faculty, departments, and institutions to the research mission. They also comment on the measures most commonly used in four areas: grants and other revenue-generating activities; publications; faculty members' research reputation and contributions to the national research enterprise; and support to the general research mission of the school. The authors conclude that quantitative information can help institutional leaders in important management decisions. However, the potential for misuse is great. The key is always to regard this information as an aid to judgment, not a substitute for it.     

A computerized faculty time-management system in an academic family medicine department.

The authors describe the development, implementation, and evaluation of a computerized faculty time-management system (FTMS) in the Department of Family Medicine at the University of North Carolina-Chapel Hill. The FTMS is presented as an integrated set of computerized spreadsheets used annually to allocate faculty time across all mission activities of the department. It was first implemented in 1996 and has been continuously developed since then. An iterative approach has been used to gain consensus among faculty about time resources needed for various tasks of all missions of the department. These time-resource assumptions are used in the computerized system. Faculty time is allocated annually by the department vice chair in negotiation with individual faculty, making sure that the activities planned do not exceed the work time each faculty member has available for the year. During this process, faculty preferences are balanced against department aggregate needs to meet mission commitments and obligations. The authors describe how the computerized FTMS is used for faculty time management and career development, department planning, budget planning, clinical scheduling, and mission cost accounting. They also describe barriers and potential abuses and the challenge of building an organizational culture willing to discuss faculty time openly and committed to developing a system perceived as fair and accurate. The spreadsheet file is available free from the authors for use in other departments.     

Aligning compensation with education: design and implementation of the Educational Value Unit (EVU) system in an academic internal medicine department.

The authors report the development of a new metric for distributing university funds to support faculty efforts in education in the department of internal medicine at the University of Kansas School of Medicine. In 2003, a committee defined the educational value unit (EVU), which describes and measures the specific types of educational work done by faculty members, such as core education, clinical teaching, and administration of educational programs. The specific work profile of each faculty member was delineated. A dollar value was calculated for each 0.1 EVU. The metric was prospectively applied and a faculty survey was performed to evaluate the faculty's perception of the metric. Application of the metric resulted in a decrease in university support for 34 faculty and an increase in funding for 23 faculty. Total realignment of funding was US$1.6 million, or an absolute value of US$29,072 +/- 38,320.00 in average shift of university salary support per faculty member. Survey results showed that understanding of the purpose of university funding was enhanced, and that faculty members perceived a more equitable alignment of teaching effort with funding. The EVU metric resulted in a dramatic realignment of university funding for educational efforts in the department of internal medicine. The metric was easily understood, quickly implemented, and perceived to be fair by the faculty. By aligning specific salary support with faculty's educational responsibilities, a foundation was created for applying mission-based incentive programs.     

Measuring contributions to the clinical mission of medical schools and teaching hospitals.

This is the final report of a panel convened as part of the Association of American Medical College's (AAMC's) Mission-based Management Program to examine the use of metrics (i.e., measures) in assessing faculty and departmental contributions to the clinical mission. The authors begin by focusing on methods employed to estimate clinical effort and calculate a "clinical full-time equivalent," a prerequisite to comparing productivity among faculty members and departments. They then identify commonly used metrics, including relative-value units, total patient-care gross charges, total net patient fee-for-service revenue, total volume per CPT (current procedural terminologies) code by service category and number of patients per physician, discussing their advantages and disadvantages. These measures reflect the "twin pillars" of measurement criteria, those based on financial or revenue information, and those based on measured activity. In addition, the authors urge that the assessment of quality of care become more highly developed and integrated into an institution's measurement criteria. The authors acknowledge the various ways users of clinical metrics can develop standards against which to benchmark performance. They identify organizations that are sources of information about external national standards, acknowledge various factors that confound the interpretation of productivity data, and urge schools to identify and measure secondary service indicators to assist with interpretation and provide a fuller picture of performance. Finally, they discuss other, non-patient-care, activities that contribute to the clinical mission, information about which should be incorporated into the overall assessment. In summary, the authors encourage the use of clinical productivity metrics as an integral part of a comprehensive evaluation process based upon clearly articulated and agreed-upon goals and objectives. When carefully designed, these measurement systems can provide critical information that will enable institutional leaders to recognize and reward faculty and departmental performance in fulfillment of the clinical mission.     

An incentive plan for professional fee collections at an indigent-care teaching hospital.

The authors describe the implementation and development of an incentive plan to improve professional fee collections at an indigent-care teaching hospital. They theorized that an incentive plan based on relative value unit (RVU) productivity would increase billings and collections of professional fees. Unique RVU targets were set for individual services based on the number of faculty full-time equivalents and average reported productivity for academic physicians by specialty. The incentive plan was based on the level of expected faculty billings, measured in RVUs, for each department. A "base + incentive" model was used, with the base budget being distributed monthly throughout the year, and the incentive held as a "withhold" to be paid at the year's end only if the billing target in RVUs was met. Additionally, a task force worked with physician billing office and the hospital to improve collections. In the first year after implementation of the system was in place, important increases were noted in total RVU productivity (30.5% over the previous year) and in collections (49.5% over the previous year). Sixteen of 23 departments exceeded their incentive targets, and it was possible to make distributions of professional fees to those departments, to be used within the hospital system to enhance clinical services. Moreover, the plan created an overall positive attitude toward billings and documentation of faculty activities. The authors believe that this kind of incentive plan will be increasingly important for academic faculty working in public hospital systems.     

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.     

Increasing the pool of educational leaders for UCLA.

The dual goals of the faculty Fellowship in Medical Education (MEF) program at the David Geffen School of Medicine at UCLA, established in 1992, are to prepare excellent teachers to serve as clerkship chairs, course chairs, or residency program directors while strengthening their dossiers for promotion based on a scholarly approach to curriculum development, implementation, and evaluation. Fellows are nominated from their departments and must demonstrate a strong interest in assuming educational leadership in their respective specialties. A total of eight fellows are accommodated each year based on interviews with the MEF faculty. The two-year program consists of two seminars and two projects focused on four objectives: to critique teaching and testing practices in medical education in light of current theories of learning; to develop and implement curricula that reflect these theories; to improve personal teaching skills through reflection and feedback; and to design and conduct an educational research or program evaluation study. An analysis of the curricula vitae of faculty members who have completed the fellowship suggest that this program continues to provide educational leaders for the school as originally intended. Of the 71 medical school faculty members who completed the MEF between 1993 and 2004 and have remained at the university, 43 (61%) have assumed new leadership roles in medical education. The evaluation data strongly suggest that the MEF has had a major role since its inception in creating a pool of faculty members with the confidence to manage the tasks of educational planning and implementation.     

Creative professional activity: an additional platform for promotion of faculty.

Academic promotion has traditionally been based on research and teaching, but faculty members' contributions to the profession may not be fully captured in those dimensions. Faculty members may influence the practice of medicine and improve the care of patients yet not obtain traditional measures of achievement through publications, grants, or teaching awards. With this problem in mind, at the University of Toronto Faculty of Medicine, the promotions committee developed and implemented a promotions criterion called Creative Professional Activity (CPA) to recognize and reward a variety of types of academic endeavors that have a demonstrable impact on medical practice and care. CPA comprises three activities: professional innovation, exemplary practice, and contributions to the development of the discipline.In this article, the authors define CPA, provide illustrative case examples, describe how faculty members document CPA, and report the use of this promotions criterion in the Department of Medicine over the last decade. The challenges of implementing CPA as a promotion criterion are described. CPA is consistent with the Department of Medicine's goal of achieving excellence through original research, education, or creative work that advances the care of patients.     

Developing a new faculty practice plan with a model for funds flow between the hospital and the plan.

The majority of academic health centers are experiencing significant difficulties balancing their research, teaching, and clinical missions while maintaining adequate financial performance. One of the major areas under intense scrutiny is the specific financial relationship between the hospital and the full-time faculty. A realignment of the funds flow between these two entities is becoming essential to the future viability and ultimate survival of many health systems. The authors describe a model that evolved as part of the integration of the faculty practice plans of their institutions when they merged into a single health system, and that provides a framework that specifically addresses these issues of funds flow. The model includes (1) a strong partnership between the hospital and the full-time faculty; (2) a governance model of chairmen, faculty, and administration; (3) flexibility for the department chairs to set salaries and make significant financial decisions relative to their departmental performances; (4) a specific formula for funds flow for graduate medical education dollars from the hospital to the clinical departments; (5) local front-end charge capture and back-end central collections; and (6) clear and consistent definitions of revenue and expense items for both partners.     

Some characteristics of academic departments of pathology in the United States. Implications for training of academic pathologists

Data concerning the activities of faculty and various characteristics of academic departments of pathology were obtained from questionnaires returned by 94 chairmen and 1571 faculty members. Data concerning manpower that was the subject of a previous report indicated that the projected supply of MD pathologists for faculty positions was significantly less than the anticipated demand. This article describes the characteristics of academic departments, particularly the activities of faculty that have bearing on the training and expectations of pathologists who are seeking faculty positions.     

Teaching medical students social responsibility: the right thing to do.

As academic medicine has become more focused on the economic pressures of the marketplace, some educators have expressed concern about whether appropriate attention is being given to the character development and moral education of medical students. The authors conclude that medical schools do indeed have a duty to teach their medical students to be socially responsible. They define a socially responsible individual as a person who takes part in activities that contribute to the happiness, health, and prosperity of a community and its members. They suggest that medical students should participate in carefully designed, socially responsible activities in order to (1) practice and have reinforced such qualities as reliability, trustworthiness, dependability, altruism, and compassion; (2) partially reimburse society for the cost of their medical education; (3) increase their exposure to a population-based approach to health care; and (4) help medical schools fulfill their social contract with the public. The authors outline the process for developing a curriculum to teach social responsibility to medical students and list some of the key questions faculty and administrators must address in the processes of development and implementation. They conclude that while faculty responsible for implementing a curriculum in social responsibility must be highly committed and prepared to address numerous difficult questions concerning the curriculum's philosophy, structure, and function, the potential benefits of such a curriculum are well worth the effort.     

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.     

A study to examine whether the basic sciences are appropriately organized to meet the future needs of medical education

There is a growing divergence between the content of research activities in the basic sciences and that of the traditional preclinical courses for medical students. A 1977 study at the University of Pennsylvania School of Medicine (Penn) examined the organization of the school's basic sciences, including surveying the research interests and departmental affiliations of 101 basic science faculty at Penn and interviewing the basic science departments chairmen there and at five other research-intensive schools of medicine. The findings demonstrated overlapping interests among basic science investigators, significant blurring of departmental boundaries, and a divergence between the faculty members' research interests and the disciplines represented by the departments in which these faculty held appointments. A second study a decade later documented that this divergence had increased. This paper also addresses the mounting concern among medical educators in response to these kinds of developments, the effect of such developments on medical education, and issues concerning the teaching of basic sciences, course content, the responsibility of schools of medicine for effecting change, and a possible model for basic science instruction.     

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.