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.     

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.     

Increasing departmental and college-wide faculty development opportunities through a teaching scholars program.

The University of Iowa Teaching Scholars Program was initiated in 1999 at the University of Iowa Carver College of Medicine (CCOM) with the overall goal of promoting leadership in faculty development related to teaching skills. Specific goals of this program are (1) to promote the development of a cadre of faculty members who have the skills to implement faculty development within their departments and the CCOM; (2) to increase departmental involvement in faculty development efforts; (3) to increase resources available for dissemination of college-wide faculty development efforts; and (4) to acknowledge the extra effort faculty put into developing their skills and knowledge in medical education and in providing continuing education to their faculty colleagues. All clinical and basic science departments in the CCOM are given the opportunity to have a faculty member participate in the program. Unlike other programs reported in the literature, competitive decisions for program participation are made at the departmental level. The three-year program combines monthly meetings and other activities to train faculty to provide faculty development in teaching skills. Each scholar develops and implements a project to address departmental faculty development needs as well as needs of other departments in the CCOM. To date (2006), 50 faculty members from 19 different departments have participated in the program with an average of 12 scholars per class. The program has resulted in a substantial increase in departmental and college-wide faculty development programming and has had a positive impact on individual scholars' teaching skills and leadership roles.     

Computer-Aided Reporting of Chest Radiographs: Efficient and Effective Screening in the Value-Based Imaging Era

In the post-PACS era, mammography is unique in adopting specialized ergonomic interfaces to improve efficiency in a high volume setting. Chest radiography is also a high volume area of radiology. The authors hypothesize that applying a novel interface for chest radiography interpretation and reporting could create high productivity while maintaining quality. A custom version of the ClearCanvas open source software, EzRad, was created with a workflow re-designed specifically for tuberculosis screening chest radiographs, which utilized standardized computer generated reports. The preliminary reports from 881,792 studies evaluated by radiology residents over a nine-year period were analyzed for productivity as RVU/FTE and compared to the finalized reports from a subspecialty attending chest radiologist for accuracy. Radiology residents were able to produce 7480 RVU/FTE per year in screening chest radiography productivity when using a custom interface at a large academic medical center with a miss rate of 0.1%. Sensitivity was 77% and specificity was 99.9%. An ergonomic user interface allowed high productivity in interpretation of chest radiography for tuberculosis screening while maintaining quality.     

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.     

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.     

Results of a gender-climate and work-environment survey at a midwestern academic health center.

AND CLIMATE determine how faculty's perceptions of medical school gender climate differ by gender, track, rank, and departmental affiliation. METHOD: In 1997, a 115-item questionnaire was sent to all University of Wisconsin Medical School faculty to assess their perceptions of mentoring, networking, professional environment, obstacles to a successful academic career, and reasons for considering leaving academic medicine. Using Fisher's exact two-tailed test, the authors assessed gender differences both overall and by track, rank, and departmental cluster. RESULTS: Of the 836 faculty on tenure, clinician-educator, and clinical tracks, 507 (61%) responded. Although equal proportions of men and women had mentors, 24% of the women (compared with 6% of men; p < .001) felt that informal networking excluded faculty based on gender. Women's and men's perceptions differed significantly (p < .001) on 12 of 16 professional environment items (p < .05 on two of these items) and on five of six items regarding obstacles to academic success. While similar percentages of women and men indicated having seriously considered leaving academic medicine, their reasons differed: women cited work-family conflicts (51%), while men cited uncompetitive salaries (59%). These gender differences generally persisted across tracks, ranks, and departmental clusters. The greatest gender differences occurred among clinician-educators, associate professors, and primary care faculty. CONCLUSIONS: Women faculty perceived that gender climate created specific, serious obstacles to their professional development. Many of those obstacles (e.g., inconvenient meeting times and lack of child care) are remediable. These data suggest that medical schools can improve the climate and retain and promote women by more inclusive networking, attention to meeting times and child care, and improved professional interactions between men and women faculty.     

Increasing women's leadership in academic medicine: report of the AAMC Project Implementation Committee.

The AAMC's Increasing Women's Leadership Project Implementation Committee examined four years of data on the advancement of women in academic medicine. With women comprising only 14% of tenured faculty and 12% of full professors, the committee concludes that the progress achieved is inadequate. Because academic medicine needs all the leaders it can develop to address accelerating institutional and societal needs, the waste of most women's potential is of growing importance. Only institutions able to recruit and retain women will be likely to maintain the best housestaff and faculty. The long-term success of academic health centers is thus inextricably linked to the development of women leaders. The committee therefore recommends that medical schools, teaching hospitals, and academic societies (1) emphasize faculty diversity in departmental reviews, evaluating department chairs on their development of women faculty; (2) target women's professional development needs within the context of helping all faculty maximize their faculty appointments, including helping men become more effective mentors of women; (3) assess which institutional practices tend to favor men's over women's professional development, such as defining "academic success" as largely an independent act and rewarding unrestricted availability to work (i.e., neglect of personal life); (4) enhance the effectiveness of search committees to attract women candidates, including assessment of group process and of how candidates' qualifications are defined and evaluated; and (5) financially support institutional Women in Medicine programs and the AAMC Women Liaison Officer and regularly monitor the representation of women at senior ranks.     

Assessing research productivity: evaluating journal publication across academic departments

Publications produced by faculty over a three-year period are used in analyzing the relative research productivity of basic and clinical science departments in a college of medicine. The citation ratings of the journals, the number of authors, and the byline position of the faculty member are used in various publication evaluation schemes. The departments vary almost tenfold in research productivity per faculty member. Results of the analysis demonstrate that the number of authors and the byline position influence departmental productivity rankings very little. Rankings are substantially affected, however, when the journals are weighted based heavily on citation ratings.     

On the Relationship Between Tooth Shape and Masticatory Efficiency: A Finite Element Study

Dental topography has successfully linked disparate tooth shapes to distinct dietary categories, but not to masticatory efficiency. Here, the relationship between four dental topographic metrics and brittle food item breakdown efficiency during compressive biting was investigated using a parametric finite element model of a bunodont molar. Food item breakdown efficiency was chosen to represent masticatory efficiency as it isolated tooth–food item interactions, where most other categories of masticatory efficiency include several aspects of the masticatory process. As relative food item size may affect the presence/absence of any relationship, four isometrically scaled, hemispherical, proxy food items were considered. Topographic metrics were uncorrelated to food item breakdown efficiency irrespective of relative food item size, and dental topographic metrics were largely uncorrelated to one another. The lack of a correlation between topographic metrics and food item breakdown efficiency is not unexpected as not all food items break down in the same manner (e.g., nuts are crushed, leaves are sheared), and only one food item shape was considered. In addition, food item breakdown efficiency describes tooth–food item interactions and requires location and shape specific information, which are absent from dental topographic metrics. This makes it unlikely any one efficiency metric will be correlated to all topographic metrics. These results emphasize the need to take into account how food items break down during biting, ingestion, and mastication when investigating the mechanical relationship between food item shape, size, mechanical properties, and breakdown, and tooth shape. Anat Rec, 299:679–687, 2016. © 2016 Wiley Periodicals, Inc.     

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?     

How do academic health centers value and encourage clinical research?

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

Improving clinical productivity in the academic setting: a novel incentive plan based on utility theory.

PURPOSE: Academic internal medicine practices face growing challenges to financial viability due to high overhead, competing institutional missions, and suboptimal physician productivity. The authors describe the development of a clinical incentive plan for a group of academic subspecialty physicians at the Dana Clinic, an outpatient setting at Yale School of Medicine, and report on results of the first year's experience under the plan. METHOD: Utility theory was used to assess the risk profile of clinic faculty and identify incentive payments that would optimize faculty benefit or "utility" while minimizing departmental costs. Under the plan, physicians who reached a productivity target based on work Relative Value Units (wRVUs) between October 2003 and November 2004 had overhead costs covered and received a fixed payment to support salary; additional incentive payments were available for those exceeding the target. Physicians failing to reach the target were responsible for their own overhead costs and received no fixed payment. Physician productivity as measured by wRVU per full-time equivalent (FTE) was compared for the year prior to, and the year following, incentive plan introduction. RESULTS: Forty-seven members of eight academic sections were included in the analysis. Median productivity improved by 34%, with 42 of 47 physicians showing improvement. Significant improvements were also noted in collections (62%) and visit volume (23%), and shifts were observed in coding patterns. CONCLUSIONS: The unique threshold-based structure of the incentive plan, as determined through utility theory modeling, as well as permitting physicians to choose how to achieve the wRVU target were key features of its success, resulting in improved productivity without increasing practice resources or faculty salaries.     

Examining the antecedents of challenge and threat states: The influence of perceived required effort and support availability

To date, limited research has explicitly examined the antecedents of challenge and threat states proposed by the biopsychosocial model. Thus, the aim of the present study was to examine the influence of perceived required effort and support availability on demand/resource evaluations, challenge and threat states, and motor performance. A 2 (required effort; high, low) × 2 (support availability; available, not available) between-subjects design was used with one hundred and twenty participants randomly assigned to one of four experimental conditions. Participants received instructions designed to manipulate perceptions of required effort and support availability before demand/resource evaluations and cardiovascular responses were assessed. Participants then performed the novel motor task (laparoscopic surgery) while performance was recorded. Participants in the low perceived required effort condition evaluated the task as more of a challenge (i.e., resources outweighed demands), exhibited a cardiovascular response more indicative of a challenge state (i.e., higher cardiac output and lower total peripheral resistance), and performed the task better (i.e., quicker completion time) than those in the high perceived required effort condition. However, perceptions of support availability had no significant impact on participants' demand/resource evaluations, cardiovascular responses, or performance. Furthermore, there was no significant interaction effect between perceptions of required effort and support availability. The findings suggest that interventions aimed at promoting a challenge state should include instructions that help individuals perceive that the task is not difficult and requires little physical and mental effort to perform effectively.     

The importance of anatomy in health professions education and the shortage of qualified educators.

The current shortage of faculty qualified to teach anatomy in U.S. medical schools is reversible. Sufficient numbers of individuals are in the pipeline to provide a future cadre of well-trained faculty members educating students in gross anatomy. The challenge is to realign departmental, institutional, and federal training grant priorities and resources, creating incentives for graduate students, postdoctoral fellows, and faculty members to stay the course and become the teachers needed to educate the next generation of health professionals. These strategies include (but are not limited to) team-teaching gross anatomy, thereby distributing the time commitments of a laboratory-based course more widely within a department; funds made available from the administration of medical schools to allow postdoctoral fellows to participate in teaching and providing compensation for the research activities; using "mission-based budgeting" to specifically compensate for faculty teaching time; and, finally, re-instituting federally funded training grants that solved this same teaching crisis in the not-too-distant past.     

A classification of developmental activities of academic family medicine supported by federal grants

Substantial funds have been awarded to academic departments of family medicine through the federal Establishment of Departments of Family Medicine grants program, initiated in 1980 under the Public Health Service Act. In 1989 the authors analyzed the successful grant applications in a sample of 61 institutions variously funded or re-funded for the grant cycles from 1980 through 1986 in order to classify the supported developmental activities. Three dimensions for explicating this activity emerged: (1) the functional area of the activity (e.g., curricular development); (2) the objectives of the activity (e.g., improving relevance of instruction); and (3) the strategies to be used to attain the objectives (e.g., addition of specialized faculty). This classification scheme provides a tentative but useful framework for characterizing departmental development.     

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.     

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.     

The difficulty of sustaining curricular reforms: a study of "drift" at one school.

In 1997, five years after a major curricular reform at the University of Michigan Medical School, the authors revisited the Goals for Medical Education (written by faculty to guide the reform process) to identify factors that had facilitated or hindered their achievement. By reviewing responses to identical questionnaires circulated to faculty in 1993 and again in 1997, they learned that considerably more lectures were being used to deliver curricular content in the first-year curriculum than the faculty thought was ideal, and that less social science, humanities, and ethics material was being presented in the first year than the faculty thought was ideal. The authors also learned that consensus between faculty basic scientists and faculty clinicians about the content that would make up an ideal first-year curriculum had diverged since adoption of the new curriculum. Movement toward decreasing the amounts of social sciences, humanities, and ethics in the first year of medical school was particularly pronounced among the basic scientists, who felt this material was being taught prematurely and at the expense of essential basic science content. In contrast, by 1997 much closer agreement had developed between the two groups regarding time they would allocate for lectures; this agreement unfortunately reflected a stagnation in the adoption of active learning methods. Movement toward increasing the amount of time for lectures in the first-year curriculum was particularly pronounced among the clinicians, who reported feeling more and more pressured to bring in clinical revenues. Based on faculty comments and the school's experience with centralized governance and centralized funding, the authors propose a direct linkage between institutional funding to departments and the teaching effort of faculty in the departments, and sufficient, centralized funding to relieve pressure on faculty and to foster educational creativity. They maintain that this may be the most effective way to guarantee ongoing innovation, support interdisciplinary teaching, and subsequently move the curriculum and teachers completely away from content that is isolated within traditional department structures. At the same time they acknowledge that changing faculty attitudes presents a challenge.