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 POD: a new model for mentoring underrepresented minority faculty.

Mentoring, long recognized as a catalyst for successful careers, is particularly important to the career development of underrepresented minority (URM) faculty. In academic medicine, mentor-protégé relationships are seriously threatened by increased clinical, research, and administrative demands and an emphasis on scholarship over citizenship. New mentoring models are needed, and they should be adaptable to a medical school's unique structure and mission. The Peer-Onsite-Distance (POD) model, developed in 2002 by the authors and introduced at the College of Medicine at the University of Arkansas for Medical Sciences, is a targeted, multilevel mentoring prototype that is built on a solid research foundation and tailored to the unique needs of URM medical school faculty. The mentee's individual needs for guidance related to career goals, resources, and the content and interaction skills that are known to be critical to successful academic careers are targeted for development. The multilevel approach provides a unique network of peer and faculty mentors who provide site-specific career guidance. Also in the network are leaders in their fields who can provide access to accurate information, cautions, predictions, and announcements of future resources or potential restrictions in academic medicine. Mentor commitments are clearly defined and time contributions are maximized. The POD model aims to promote retention and advance the careers of URM faculty by wrapping them in a protective cushion of interpersonal and intrapersonal support. The flexibility of the design allows for adaptation to any institution's unique structure and mission.     

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.     

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 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.     

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.     

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.     

Challenges in Recruiting,Retaining and Promoting Racially and Ethnically Diverse Faculty

Background

Despite individual and institutional awareness of the inequity in retention, promotion and leadership of racially and ethnically underrepresented minority faculty in academic medicine, the number of such faculty remains unacceptably low. The authors explored challenges to the recruitment, retention and promotion of underrepresented faculty among a sample of leaders at academic medical centers.

Baylor's program to attract minority students and others to science and medicine

To attract minority students and others to careers in medical practice and biomedical research and to prepare them for such careers, Baylor College of Medicine conducts a variety of summer enrichment programs and other programs to improve how science is presented to students in their preprofessional years from elementary grades through college. These efforts aim to increase the number of competitive candidates for medical school, particularly those from minority groups underrepresented in medicine. They entail close collaboration between the Baylor administration and faculty from Texas public schools and two-year and four-year colleges and universities. The authors discuss the rationale for these programs and comment about the need for institutional commitments of faculty and financial support. They note that these programs are an investment in the future and that longitudinal assessment is needed to determine their ultimate success.     

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.     

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.     

Sharing digital teaching resources: breaking down barriers by addressing the concerns of faculty members.

PURPOSE: Regional and institutional databases have been created to improve access to educational resources and to avert unnecessary duplication. The growth and success of these databases depend upon the willingness of faculty members to contribute their materials. This qualitative study seeks to identify the barriers that block the free exchange of educational multimedia and the incentives that could be created to overcome educators' concerns. METHOD: In 2001, 34 faculty members from 13 U.S. medical schools each participated in one of five focus groups. They responded to three hypothetical scenarios depicting opportunities for sharing educational resources. Participants' responses were categorized hierarchically and sent back to them for feedback. RESULTS: Participants strongly supported multimedia databases, particularly those that serve a national audience. Obstacles for contributing materials included the lack of institutional recognition for educational innovation, confusing intellectual property policies, the hassle involved in sharing materials, and the perceived commercial potential of the materials. Peer review of educational materials was seen as an important incentive. CONCLUSIONS: Medical schools could benefit from the free exchange of high-quality educational multimedia but need to address the concerns of faculty by clarifying institutional copyright rules, streamlining the donation process, and providing assistance with cataloging assets. Removing departmental pressures to commercialize materials and recognizing peer-reviewed donations as academic achievement could foster a culture of sharing.     

Organizational models for medical school-clinical enterprise relationships.

Changes in the organization, financing, and delivery of health care services have prompted medical school leaders to search for new organizational models for linking medical schools, faculty practice groups, affiliated hospitals, and insurers-models that better meet the contemporary challenges of governance and decision making in academic medicine. However, medical school leaders have relatively little information about the range of organizational models that could be adopted, the extent to which particular organizational models are actually used, the conditions under which different organizational models are appropriate, and the ramifications of different organizational models for the academic mission. In this article, the authors offer a typology of eight organizational models that medical school leaders might use to understand and manage their relationships with physicians, hospitals, and other components of clinical delivery systems needed to support and fulfill the academic mission. In addition to illustrating the models with specific examples from the field, the authors speculate about their prevalence, the conditions that favor one over another, and the benefits and drawbacks of each for medical schools. To conclude, they discuss how medical school and clinical enterprise leaders could use the organizational typology to help them develop strategy and manage relationships with each other and their other partners.     

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

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

A curricular model for the training of physician scientists: the evolution of the Duke University School of Medicine curriculum.

Duke University School of Medicine offers an unusual doctor of medicine educational program. The core basic sciences are taught in year one, core clinical clerkships are completed in the second year, the entire third year is devoted to scholarly investigation, and elective rotations are fulfilled in the fourth year. The creation of this unique structure presented many challenges and is the product of a desire of key faculty 40 years ago to change radically the way medical education was taught. Over the years, improvements have been made, but the underlying principles of these visionary leaders have been retained: inquire not just acquire, flexibility of choice, and in-depth exploration. In the spirit of innovation that was established 40 years ago, leaders and faculty at Duke developed a new curricular model in 2004, called Foundation for Excellence, which is anchored in integrated, interdisciplinary innovation. The authors describe the process of curricular reform and provide a detailed overview of this unique approach to medical education. In keeping with Duke's mission to graduate clinician-researchers and clinician-educators, reducing the basic science curriculum to one year created a year saved, which students are now required to devote to scholarly pursuits. The authors argue that adopting a similar one-year basic science curriculum would make instructional time available for other schools to achieve their own institutional goals.     

Collision course: the privatization of graduate medical education at one university.

On December 18, 2003, Tenet Healthcare Corporation, an investor-owned hospital corporation, announced the closure of Medical College of Pennsylvania Hospital, a historic institution that was home to many of Drexel University College of Medicine's (DUCOM's) faculty, residents, and medical students. The authors summarize the steps that were taken and lessons learned to avoid a disruption in the education of over 200 residents. The authors highlight the response by the medical school; the concerns of the Accreditation Council for Graduate Medical Education (ACGME); the interaction between the Center for Medicare and Medicaid Services (CMS) and the ACGME; the importance of the designated institutional official (DIO) in a crisis situation; and the role of residents as students versus employees when their employer wishes to move or "trade" them to another institution. Through the lens of the DUCOM experience, the authors explore the legal, political, and educational conflicts that occur when an investor-owned company or private hospital employs residents but another entity holds moral and academic accountability for their future. Finally, the authors outline five lessons learned: (1) the important role the ACGME plays as the educational conscience of graduate medical education (GME), (2) the dramatically different roles that the ACGME and the CMS play in regulating and funding the national GME system, (3) the need for constant communication with the affected residents, (4) the important role that the DIO plays in GME, and (5) the need for medical school leaders to remain focused on their educational mission and responsibilities to young physicians.