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.     

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.     

The impact of a program for systematically recognizing and rewarding academic performance.

PURPOSE: To describe an academic performance incentive system (APIS) and faculty perception of it; explore the impacts of incentive level, faculty rank, clinical practice volume, and administrative responsibility on academic productivity; and describe the APIS's use in maintaining congruence between department mission and activities. METHOD: A list of teaching, research, and academic service activities was developed, which full-time faculty (n = 33) used to report activities. Clinical faculty members received incentive income based on credits earned. APIS initially distributed 1% of practice plan receipts (subsequently increased to 3% and then 5%). Productivity was measured by differences in APIS points achieved. Satisfaction of all faculty participants was measured by survey. RESULTS: Faculty members (n = 20) who participated throughout averaged 22 credits per month (nine to 42 credits), and quarterly incentive bonuses ranged from 145 US dollars to 6,128 US dollars. Average credits earned per month were 24 for the 1% incentive, 23 for the 3% incentive, and 20 for the 5% incentive. Faculty members with administrative responsibilities were as productive academically as were their non-administrative counterparts. Senior faculty members were as productive as junior faculty. Faculty members who were more productive clinically were more productive academically. Seventy percent of respondents reported they were either very satisfied or somewhat satisfied with the APIS. Seventy-eight percent felt that the APIS accurately reflected their academic productivity. Most respondents (81%) felt that the amount of money allocated to the incentive system was appropriate (15% felt it should be increased and one respondent recommended reduction). CONCLUSIONS: The APIS system has been well accepted by faculty and allows for data-driven discussion of the department's mission and activities.     

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-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.     

An initiative in mentoring to promote residents' and faculty members' careers.

Internal medicine trainees and faculty recognize the value of effective mentoring to help meet the personal and professional needs of residents. However, the paradigm of the mentor-trainee relationship is seriously threatened by increased clinical, research, and administrative demands on both faculty and housestaff. Moreover, the current criteria for promotion in most teaching hospitals emphasize scholarship, rather than citizenship, so activities such as mentoring devolve to a lower priority. In 2000, the Department of Medicine at Brigham and Women's/Faulkner Hospital initiated a program to improve the effectiveness of housestaff mentoring and recognize faculty contributions to resident career development. The authors report the feedback received from a survey of the 2002-03 medical housestaff (74% response rate) and describe their experiences with the initiation of this program. Over 90% of the housestaff respondents thought it important that the Department assigns an individual faculty mentor. In practice, time-consuming professional responsibilities made meetings difficult, but most pairs supplemented their interactions with e-mail. Discussions primarily focused on career advice and support. Housestaff thought mentors were helpful and available when needed. The department has established new metrics for recognizing faculty mentoring and now publicly rewards mentoring excellence. Of note, unassigned mentoring has increased since the initiation of this program. The authors conclude that the formal mentoring program has ensured that all trainees are provided with a mentor, which has facilitated faculty-housestaff interactions and increased recognition of faculty contributions to mentoring.     

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.     

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.     

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 pediatric intern retreat: 20-year evolution of a continuing investment.

For the past 22 years the interns in pediatrics at the University of Washington and Children's Hospital and Regional Medical Center have been relieved of all clinical duties in order to participate in a five-day retreat. The retreat provides an opportunity for the interns to learn more about their classmates, build stronger bonds, and provide mutual support. This retreat has been supported by the hospital, the department of pediatrics, faculty, fellows, and community physicians. The authors describe the history of the Intern Retreat, present its goals, daily activities, and faculty, and discuss how the retreat is funded and supported by the hospital and the medical community.     

Recognizing the value of community involvement by AHC faculty: a case study.

Physicians seek connections to their communities. Some health care and academic leaders believe that facilitating the creation of more such community connections is one way to reverse the trend of waning social and political legitimacy for the U.S. medical profession. For academic health centers (AHCs), such connections can maintain local and state support crucial to their long-term success. Multiple barriers exist to such involvement, especially for physicians in AHCs, where work done beyond direct patient care, administration, and research rarely contributes to the tenure and promotion process. The authors present a case study to show how one department in an AHC, beginning in the late 1990s, has been overcoming these barriers to incorporate the scholarship of community engagement into its mission and structure. The case study incorporates theoretical underpinnings to crystallize the following lessons that the department has learned so far: (1) If academic departments wish community service to be a central part of their mission, they need ways to institutionalize community engagement within organizational structures. (2) Community engagement can be scholarly. (3) If faculty members are to be recognized for their service activities, measures are necessary to determine what constitutes "excellence" and "scholarship" in community service. (4) Scholarship of community engagement goes beyond performing service activities in the community.     

Status of faculty affairs and faculty development offices in U.S. medical schools.

PURPOSE: To collect baseline data and describe how medical schools handle faculty affairs and faculty development responsibilities. METHOD: In January 2000, the authors surveyed faculty affairs designees at 125 U.S. medical schools, using a questionnaire developed in consultation with a group of faculty affairs professionals. RESULTS: The responding 76 medical schools (61%) support over four times as many offices of faculty affairs as faculty development offices. Core functions of faculty affairs offices include administrative support for appointments, promotions, and tenure committees; faculty information and policies; faculty governance processes; and department chairs' recruitment support and personnel management issues. CONCLUSION: While a consensus is emerging about the functions of a faculty affairs office, no school has a comprehensive faculty development system, in contrast to most industries, which must be more forward-looking to compete for talent.     

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.     

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.     

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.     

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.     

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 relation of faculty academic activity to financing sources in a department of medicine

Academic medical departments confront important changes in funding sources and consequent pressure to change faculty activities. Valid information has often been lacking concerning the existing relations of faculty activity to funding sources. We examined those relations in the Stanford Department of Medicine through a combination of randomized observations of faculty and faculty self-reports over a period of one year. For an average 62-hour workweek, there was approximate consonance between types of activities and sources of salary support. Sensitivity analyses indicated that even sizable errors in self-reports would not have changed the outcomes substantially. Over 60 per cent of the activity involved "joint products," representing two or more categories of activity. There was wide variation in activities and fund sources between divisions. Per full-time faculty equivalent, research generated far more income than the most lucrative specialty practice; thus, at least in this type of department, attempts to compensate for lost research revenue by intensifying clinical practice will probably fail and undermine present research activities. The method of analysis used here may be useful in improving prospective planning by departments and by larger medical-policy bodies, particularly in the public sector.     

Evaluating faculty performance: a systematically designed and assessed approach.

The authors explain how the Department of Family Practice and Community Health (DFPCH) at the University of Minnesota School of Medicine has responded to the need to create for its faculty an evaluation system that provides information for both feedback and merit-pay decisions. The development process, begun in 1996, is described, and its present format detailed. Also presented are the results of a 1999 assessment of the system, which found high satisfaction among the faculty and the department head. In particular, this system has allowed the department head to have a more objective basis for making salary decisions, to increase his role as coach, and to commit more time to career correction and/or development. Other observed outcomes include an enhanced ability to track faculty productivity, increased clarity in organizational structure and goals, increased research productivity, and early retirement of senior faculty receiving low evaluations. The key components of the DFPCH system mirror recommended elements for the design of faculty evaluation systems offered by evaluation professionals. Specific elements that the DFPCH found critical to success were stable and supportive departmental and project leadership, supportive faculty, skilled staff, a willingness to weather resistance to change, tailoring of the system to the department's specific needs and culture, and a willingness to allow the process to evolve. A key question that the evaluation system has evoked at the DFPCH is whether "merit" equals "worth"; that is, does the collective meritorious work of faculty members effectively address program and departmental goals?