Report 6 The Blue Ridge A C A D E M I C H E A LT H G R O U P Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 A Four-Point Agenda . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Mission Renewal and Realignment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Aligning with Societal Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Recommendation and Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Organizational Innovation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Reform with Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Barriers to Change . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Change in Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Change in Clinical Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Change in Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Recommendation and Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 Enabling Knowledge Workers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Optimizing Performance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 Clarifying Expectations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23 Measuring Quality and Outcomes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24 Bringing Good Things to Life . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 Recommendations and Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Overcoming Cultural Barriers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Developing New Archetypes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31 Leadership Development . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34 Recommendations and Action Steps . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .37 About the Blue Ridge Academic Health Group . . . . . . . . . . . . . . . . . . . . . . . . .39 About the Core Members . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .40 About the Invited Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .46 Appendix: Baylor Metrics 2001 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Reproductions of this document may be made with the written permission of the University of Virginia Health System by contacting Elaine Steen, University of Virginia Health System, Box 800413, Charlottesville, VA 22908 Email: ebs9g@virginia.edu Creating a Value-driven Culture and Organization in the Academic Health Center is the sixth in a series of reports by the Blue Ridge Academic Health Group. The recommendations and opinions expressed in this report represent those of the Blue Ridge Academic Health Group and are not official opinions of the University of Virginia. This report is not intended to be relied upon as a substitute for specific legal or business advice. For questions about this report, contact: Don E. Detmer, M.D., University of Virginia, Phone: (434) 924-0198 Email: ded2x@virginia.edu Copyright 2001 by the Rector and Visitors of the University of Virginia The Blue Ridge Academic Health Group Report 6 Creating a Value-driven Culture and Organization in the Academic Health Center The Blue Ridge Academic Health Group Mission The Blue Ridge Academic Health Group seeks to take a societal view of health and health care needs and to identify recommendations for academic health centers (AHCs) to help create greater value for society. The Blue Ridge Group also recommends public policies to enable AHCs to accom- plish these ends. Members David Blumenthal, M.D., Professor of George F Sheldon, M.D., Chairman and . Medicine and Health Care Policy, Harvard Professor, Department of Surgery, School of Medical School; Director, Institute for Medicine, University of North Carolina at Health Policy, The Massachusetts General Chapel Hill (until September 1, 2001); Hospital Scholar in Residence, Burroughs Wellcome Fund Enriqueta C. Bond, Ph.D., President, Burroughs Wellcome Fund Katherine W. Vestal, Ph.D., Vice President, Cap Gemini Ernst & Young U.S., LLC Robert W. Cantrell, M.D., Vice President and Provost (until July 2001), Director, Invited Participants Virginia Health Policy Center, University of Virginia Health System Haile T. Debas, M.D., Dean, School of Medicine, Vice Chancellor for Medical Don E. Detmer, M.D., Dennis Gillings Affairs, University of California, Professor of Health Management, Judge San Francisco Institute of Management Studies, University of Cambridge* Tipton Ford, Senior Manager, Cap Gemini Ernst & Young, U.S., LLC Michael A. Geheb, M.D., Senior Vice President for Clinical Programs, Oregon Arthur Garson, Jr., M.D., M.P.H., Senior Vice Health Sciences University President and Dean for Academic Operations, Baylor College of Medicine Jeff C. Goldsmith, Ph.D., President, Health Futures, Inc. John Lynch, Vice President, Global Human Resources, GE Medical Systems, General Michael M.E. Johns, M.D., Executive Vice Electric Company President for Health Affairs, Director, the Robert W. Woodruff Health Sciences Center, Staff Emory University Cap Gemini Ernst & Young U.S., LLC Peter O. Kohler, M.D., President, Oregon Jacqueline Lutz, Associate Director Health Sciences University University of Virginia Edward D. Miller, Jr., M.D., Dean and Chief Charlotte Ott, Senior Executive Assistant Executive Officer, Johns Hopkins Medicine, Jon Saxton, J.D., Policy Analyst** The Johns Hopkins University Elaine Steen, M.A., Policy Analyst Jeffrey Otten, M.A., M.B.A., President, Founders Brigham & Women’s Hospital The University of Virginia and Cap Gemini Mark Penkhus, M.H.A., M.B.A., Executive Ernst & Young, U.S. LLC founded the Blue Director and Chief Executive Officer, Ridge Academic Health Group in 1997. Vanderbilt University Hospital *Chair Paul L. Ruflin, M.B.A., Vice President, **Editor Cap Gemini Ernst & Young U.S., LLC Introduction concern with deficiencies and inconsis- What is new and significant must tencies in the quality of health care always be connected with old roots, delivery services. the truly vital roots that are chosen The health care sector is clearly laboring with great care from the ones that under the strains of this changing and merely survive. demanding environment. The new market- place is squeezing the financial resources – Béla Bartók, Composer and compensation available to health providers and organizations. Societal needs, expectations, and aspirations for the A Four-Point Agenda health care system have changed and are growing. Academic health centers (AHCs), in particular, continue to face great chal- The academic physician, academic med- lenges in adapting their multiple service icine, and the health professions in general and academic missions to changing socie- are in the midst of an extended period of tal, financial, and service requirements. organizational and professional turbu- lence. Beginning with the explosive AHCs have adopted measures to improve growth of managed care in the 1980s, the service, cut costs, and increase productivity. relatively closed, professionally self-regu- They are learning how to do more with lated health services sector has been less. They have also worked to develop pushed into a more classically competitive new capabilities and revenue streams in an marketplace (Blue Ridge Academic Health attempt to shore-up strained academic and Group, 1998b). The 1990s brought addi- clinical resources. These efforts increase tional impetus for change with shifting the service and performance expectations public policy, changing demographics, for faculty and staff who find it increasing- increasing consumerism, and the growing ly difficult to pursue research and teaching influence of information technologies goals. In almost every aspect of the chang- (Blue Ridge Academic Health Group, ing health care environment, strategies for 2000a and 2001). Now, at the turn of the competitiveness and fiscal discipline have new century, there is renewed public been in contest with long-established 2 organizational structures, processes, norms, values, and traditions of the health professions. The ensuing conflicts have been difficult to manage. As a result, AHCs are experiencing significant internal turmoil. Faculty morale and loyalty to the academic institution are being affected. Traditional AHC organizational structures and management solutions are fast becoming insufficient, if not obsolete. In the face of this difficult environment, AHCs must address cultural and organiza- tional barriers to professional and institu- tional success in the health system of the 21st century. They must update their missions and organizations and adopt new approaches to supporting and motivating their staff. To do so, the Blue Ridge Group believes that AHCs must pursue a four- point agenda: • Mission Renewal and Realignment – AHCs The Blue Ridge Academic must renew and, where necessary, realign their Health Group goals, values, and missions to meet societal needs and aspirations. The Blue Ridge Academic Health Group (Blue Ridge Group) studies and reports on issues of fundamental importance to • Organizational Innovation – AHCs must improving our health care system and to enhancing the restructure and realign their organizations to enable optimal performance and support ability of the academic health center (AHC) to sustain updated missions and goals. optimal progress in health and health care through sound research – both basic and applied – and health professions • Personnel Management – AHCs also must education. Five previous reports have described opportuni- adopt new human resources and management ties to improve AHC performance in a changed health care systems necessary to support today’s environment and to leverage AHC resources in achieving knowledge workers. threshold improvements in health system access, quality, and cost. The Blue Ridge Group has provided guidance on • Cultural Reform – AHCs and the health improving management, strengthening financial perform- professions together must address and realign ance, enhancing leadership, developing knowledge man- some important aspects of traditional academic and professional culture. agement and Internet-based capabilities, and developing a more rational, comprehensive, and affordable health care system (Blue Ridge Academic Health Group 1998a; 1998b; 2000a; 2000b; 2001). In this, its sixth report, the Blue Ridge Group considers the need for academic health centers to address the cultural and organizational barriers to professional, staff, and institutional success in a value-driven health system. 3 Exhibit 1: Recommendations Mission Renewal and Realignment • AHCs, organized medicine, and the health professions • AHCs should supplement the culture of the independent should renew and, where necessary, realign their goals, investigator with a culture that supports demonstrated ability values, and missions to better address societal needs and to establish and be a significant contributor to, or leader of, aspirations for our health care system. fruitful and meaningful collaborations and teams. Organizational Innovation • AHCs should supplant the traditional ideal of the “triple • AHCs should develop and implement organizational threat” with one that emphasizes: innovations and programs that enable faculty and staff to achieve societal health care needs and to create a value- • Excellence in scholarship and/or achievement in one or driven health care system. more of the core academic mission areas: student-cen- tered education, discovery-centered research, or care- Enabling Knowledge Workers centered research or innovation. • To enhance value-creation, motivate performance, and improve quality and outcomes, AHCs must develop a new • Excellence in achievement and/or leadership in the core understanding of knowledge workers and the types of orga- service mission: patient-centered care. nizational systems and processes required to manage and lead them. AHCs should commit to ongoing leadership, • Excellence in achievement and/or leadership in commu- professional, and staff development as an integral part of nity, professional, and institutional service in measurably each mission. meeting societal needs and aspirations for our health care system. • AHCs should develop new and improved human resource capabilities that enable routine performance appraisals, iden- • AHCs should replace the archetype of the ego-centric, tification of new talent, cultivation of skills, and mentoring of authoritarian, or otherwise organizationally dysfunctional faculty and staff. personality and pursue creation of a new cultural standard that values the stellar, brilliant individual with a strong Overcoming Cultural Barriers personality who leads collective change, inspires confidence, • AHCs and health professional organizations should and motivates performance among peers, other knowledge actively work to reform their cultures and archetypes of workers, and staff. desirable behavior. 4 Mission Renewal and Realignment Aligning with Societal Needs For more than half a century, AHCs and declining revenues, and increased admin- the medical profession have provided vital istrative and regulatory burdens, when roots of leadership in the progress of headlines focus on issues relating to prob- health care, in biomedical and behavioral lems with clinical trials, lapses in medical science, in the education of health profes- record security, or any other sionals and scientists, and in service to performance problems. the community. Yet the intense focus on hospital-based research, training, and Despite the intrusion of market forces care, combined with proliferating technol- into the health sector, there is still an ogy, resulted in a very expensive system understanding that health care is a special that was not meeting important health service. Not only do health care services needs of millions of citizens. Despite depend on trust between the patient and many impressive achievements, signifi- health professional, but they also generate cant flaws and inequities still exist in safe- a public good in the form of a healthy, ty, quality, cost, and access. At the end of productive society. AHCs are beneficiaries the 20th century, more than 40 million of substantial public investment and they Americans lacked health insurance. play a unique role in the nation’s health Access to and quality of health care varied infrastructure. They have a particular widely across regions, populations, and responsibility to assure that they under- localities. The health of the population, as stand and are meeting the public’s needs. measured by variables such as life expectancy and infant mortality, lag AHCs and the health professions must ask behind most industrialized countries whether their missions, values, and goals (Rice, 1994). Two recent reports from the are well aligned with those of society. The Institute of Medicine (IOM) identified sig- IOM has provided indispensable guidance nificant problems with patient safety and for mission realignment and for moving the quality and consistency of health care towards the type of value-driven health delivery (IOM, 1999 and 2001). system that the Blue Ridge Group advo- cates (see Exhibit 2) (Blue Ridge The Balanced Budget Act of 1997, strip- Academic Health Group, 1998b). ping more than $100 billion in payments and subsidies out of the health care sys- tem over five years, was a watershed event The real cure can come only out in public policy towards health care of changes in national policy and providers and the rising costs of health care. The fact that some monies have priorities when the American public recently been restored does not change has had enough of this uncontrolled the basic picture. It is increasingly diffi- chaos we call our health care system. cult to maintain public sympathy over such issues as reduced reimbursements, – Halie Debas,M.D., Dean UCSF 5 Exhibit 2: The Value-Driven Health System One of the most important findings is that our existing systems of care are inade- A value-driven health system is grounded in the principle quate given the complexity of modern that a healthy population is a paramount social good. It is a health system that promotes the health of individuals health care and the growth in the health and the population by providing incentives to health care sciences knowledge base. Health profes- providers, payors, communities, and states to improve sionals cannot provide high quality care population health status and reward cost-effective health management. Two kinds of incentives exist within a value- in a delivery system with deficient driven health system. First, there are incentives for individual processes, inadequate information sys- citizens (patients), health care professionals, health delivery tems, and unmanaged change to the point organizations, payors, and communities to seek and maintain health. Health insurance premiums, reimbursement of turmoil. In a manner akin to many of rates, and grants to communities can all be structured to our past recommendations, the IOM reward behaviors and strategies that advance health. described our health system as lacking Second, providers compete on the basis of quality and effi- clarity of purpose, commonality of inter- ciency for populations to manage (where quality is defined in terms of health of the community or region as well as ests, and the shared values necessary to health of individuals). To do so, however, requires a fully guide the various constituents of the insured population (universal coverage) so that population health care system – from patients to health management strategies can be implemented. health professionals to policy makers – towards system-wide improvement. The IOM proposed a national agenda that includes the adoption of a “national In its report, Crossing the Quality Chasm: statement of purpose” (see Exhibit 3) and A New Health System for the 21st Century, a set of six “aims,” or target areas, for the IOM surveyed the broader landscape improvements in health care systems. of quality issues in health care and found The Blue Ridge Group strongly endorses a large gap between the promise and the this effort and the set of proposed aims, realities of the health care system (IOM, which prescribe that health care should 2001). Describing the last quarter of the be (IOM 2001, p. 6): 20th century as the “era of Brownian motion in health care,” the report sug- • Safe – Avoiding injuries to patients from the care that is intended to help them. gests that this tumultuous period of “mergers, acquisitions and affiliations” • Effective – Providing services based on has produced a great deal of organization- scientific knowledge to all who could benefit and refraining from providing services to those not al turmoil but little in the way of signifi- likely to benefit (avoiding underuse and overuse, cant or lasting improvements in either the respectively). quality of health care or in the health status and outcomes for the population. • Patient-centered – Providing care that is respectful and responsive to individual patient A central message is that care delivery in preferences and needs and ensuring the future must be constructed on three that patient values guide all clinical decisions. pillars: scientific evidence, well-designed systems, and patient-centered care. • Timely – Reducing waits and sometimes harmful delays for both those who receive and those who give care. 6 • Efficient – Avoiding waste, including waste of building on the knowledge, skills, and equipment, supplies, ideas, and energy. dedication of the healing professions, the • Equitable – Providing care that does not vary in IOM has provided an important rallying quality because of personal characteristics such point for the health care system and for as gender, ethnicity, geographic location, and AHCs and health professionals as they socio-economic status. seek to refine their missions and build a value-driven health care system. The Blue Ridge Group believes the state- ment of purpose reflects societal aspira- While the six IOM aims are directed at tions for our nation’s health care system the health care delivery system, they also with which AHCs and the health profes- have implications for AHC research and sions should seek to align their missions education domains. The research agenda and goals. can support the emerging health system by focusing on issues such as the contin- These aims can also serve as consensus ued development of quality metrics and drivers for a value-driven health care sys- development of protocols to reduce varia- tem that provides universal coverage tion in the disease management process. through a combination of public and pri- Moreover, AHCs need to work across dis- vate mechanisms. With universal cover- ciplines and professions to align the size, age, health care organizations can be content, and structure of their educational incentivized to manage and improve the programs with the distribution of health care of individuals and populations professionals needed in the 21st century through the development of effective, evi- health system. dence-based systems. Research suggests that huge gains in economic value could be achieved for society by the systematic population-based application of even modest advances in treatment of common diseases (Murphy and Topel, 1999). AHCs can unleash their reserves of creativity to catalyze the development of new popula- tion health management strategies, drive Exhibit 3: Statement of Purpose for the Health Care System competition to develop better ways to measure and reward quality and efficacy All health care organizations, professional groups, private, and public purchasers should adopt as their explicit of care, and create more value for the purpose to continually reduce the burden of illness, injury, health care dollar. and disability, and to improve the health and functioning of the people of the United States (IOM, 2001, p. 39). Towards this end, the IOM has articulated clear and powerful goals that AHCs, health professionals, and the public can embrace. By focusing the public policy spotlight on the inadequacy of existing delivery systems and system goals, and in 7 Mission Renewal and Realignment Recommendation and Action Steps Recommendation • AHCs, organized medicine, and the • AHCs should adopt and advocate the health professions should renew and, goal of transitioning our national health where necessary, realign their goals, val- care system to a value-driven model of ues, and missions to better address soci- universal coverage and population health etal needs and aspirations for our health management through a combination of care system. public and private mechanisms, as recommended by the Blue Ridge Group Action Steps in its 1998 report, Promoting Value and Expanded Coverage: Good Health is • AHCs should adopt and advocate the Good Business. societal needs and aspirations articulated by the Institute of Medicine in its report, Crossing the Quality Chasm: A New Health System for the 21st Century. These include the need for a health care system that is safe, effective, patient-cen- tered, timely, efficient, and equitable. 8 Organizational Innovation Reform with Change The AHC, like all provider organiza- Some AHCs have experimented with, and tions, seeks to adopt competitive practices adopted, a “mission management” and the fiscal discipline to compete in the approach to organizational and personnel medical marketplace. At the same time, management. With this approach, AHCs AHCs must provide an environment that attempt to develop systems appropriate encourages people to pursue quality, fos- for organizing work and managing per- ter creativity, promote discovery, and nur- sonnel within each separate mission: ture future health professionals, scientists, research, education, patient care and, and educators. AHCs have had limited sometimes, community service (Bulger et success in achieving this balance, in part al., 1999). A great deal of work has gone because traditional AHC organizational into creating new metrics for guiding and structures and management approaches are evaluating faculty performance unable to meet contemporary challenges. (D’Alessandri et al., 2000; Sussman et al., 2001). AHCs and teaching hospitals have employed a variety of organizational and A major and unintended consequence of personnel management strategies to these new organizational and manage- improve their competitiveness and fulfill ment initiatives is that faculty are buffeted academic and service obligations. by shifting and sometimes conflicting pro- Organizational strategies have included fessional and institutional expectations vertical and/or horizontal integration of and responsibilities. Traditional areas of clinical units and departments, large insti- faculty responsibility, authority, and tutional and hospital mergers, acquisition autonomy are being circumscribed and development of primary care “feeder” (McKinlay and Arches, 1985; Eisenberg, practices, aggressive cost reductions at 1999). Unable to devote sufficient time or owned or affiliated hospitals, various effort to research, teaching, or profession- forms of administrative process consolida- al self-development – goals and activities tion, reorganization of care processes and that are fundamental to their professional policies, expansion of outpatient capacity, identity and personal values – many faculty, and improvements in information tech- especially clinical faculty, feel devalued nology and organizational communica- and disillusioned (Kataria, 1998). tions. In some instances, they even Recently published research confirms that became insurers through creation of clinical faculty satisfaction is below that health care plans. Personnel management of other medical school faculty strategies have included various forms of (Blumenthal et al., 2001). Many question individual and clinical unit productivity whether academic values and missions are goals and incentivization schemes tied to being replaced wholesale by “corporate” salaries and bonuses, departmental and values (Blake, 1996; Relman, 1994). One hospital discretionary funds, dean’s funds respected commentator has suggested that and dean’s taxes (Task Force on Academic medical schools are neglecting their uni- Health Centers, 2000). versity missions and appear to be regress- ing towards the proprietary school model 9 that was the subject of Abraham Flexner’s In articulating the growing public and scathing report on the status of medical professional dissatisfaction with the sta- schools in 1910 (Ludmerer, 1999). tus, trajectory, and priorities of the health care system, the Crossing the Quality Further, despite these and other ambitious Chasm report reaches a conclusion at initiatives, a substantial number of AHCs once bold and yet almost intuitively obvi- continue to struggle to maintain operating ous by now to professionals and the pub- margins. A report to the Commonwealth lic alike: Fund Task Force on Academic Health Centers found in the year 2000 that 14 of “The current care systems cannot do the job. 17 research-intensive AHCs experienced Trying harder will not work. Changing sys- either an operating loss, a bond down- tems of care will.” (IOM, 2001) grade, or a negative bond rating (Weisman and MacDonald, 2001). This This is a pivotal conclusion in the public seriously affects the financial strength of dialogue concerning our health care sys- AHCs and limits the traditional utilization tem: The quality of health care and access of clinical revenues to cross-subsidize that Americans deserve and desire cannot education, research, and administrative be achieved by driving higher productivi- costs within the AHC and throughout the ty in existing systems of care – or by fur- university. ther consolidating, streamlining, or expanding these systems. Instead, new It has become increasingly clear that systems must be designed. many strategies being employed by AHCs, including most “mission management” “Health care has safety and quality prob- strategies, are designed primarily to lems because it relies on outmoded systems improve the efficiency and effectiveness of of work. Poor designs set the workforce up traditional systems rather than to define to fail, regardless of how hard they try. If we new ones. This is a typical response that a want safer, higher-quality care, we will need leading medical sociologist has aptly iden- to have redesigned systems of care, including tified as the pursuit of “reform without the use of information technology to support change” (Bloom, 1988). The process of clinical and administrative processes.” reform without change is likely a major (IOM, 2001) reason why, after years of various imple- mentations, most AHCs continue to expe- It is vitally important that AHCs (and all rience turmoil and uneven progress in other organizations involved in health balancing missions and achieving goals. delivery) take the measure of this asser- tion. It is likely that many existing organi- One of the many tests of leadership in zational structures within AHCs – their this new environment, following on the schools, clinics, and hospitals – are inade- need to revisit and realign values and mis- quate. The ability of health professionals sions, is to lead necessary organizational and the health care system to perform to change. Once again, the IOM report, their potential depends upon the develop- Crossing the Quality Chasm, provides ment of more appropriate organizational, important guidance. informational, and related systems. 10 This, of course, does not make the exist- referral networks, and establishing indi- ing organizations and processes easy to vidual hospital privileges and affiliations. redesign or to replace. But difficult or not, For both academic and non-academic reform with change is imperative. physicians, often their most meaningful institutional ties have been to their pro- Barriers to Change fessional (usually medical or surgical spe- cialty) organizations. One of the fundamental impediments to optimal performance within AHCs is the On the basic science side, the departmen- organization of faculty in traditional, dis- tal structure has served very much the cipline-based departments. Whether seen same functions. AHC and medical school as an accident of history or as a rational basic science departments developed development within 20th century medical along classical divisions dating back to and academic structures, it is clear that the origins of the biomedical and behav- the traditional departmental organization ioral sciences: first chemistry, biology, and is often a barrier to the achievement of the physical sciences, and later proliferat- 21st century missions and goals. ing into subspecialties, including microbi- ology and molecular genetics, cell biology, On the clinical side, the departmental neurobiology, molecular pharmacology, structure reflects training regimens regu- pathology, biomedical statistics, biomedical lated by well-established specialty certifi- engineering, and most recently, genetics. cation boards that grew as new technolo- gies and discoveries in biomedical science These basic science departments too, encouraged the proliferation of subspe- evolved as structures designed to promote cialties. Clinical departments evolved as traditional values, priorities, and rewards. faculty-centered structures designed to Individual creativity and achievement in promote traditional faculty and profes- research, including success in winning sional values, priorities, and rewards. In extramural research funding, have been the majority of medical schools, and cer- most highly valued and rewarded. tainly in those considered to be (or striv- ing to be) elite, departmental “silos” have The middle of the 20th century until the long served as mechanisms to ensure free- early 1980s was an era of expanding dom of inquiry and protected time for health care expenditures, increasing rates reflection, research, and related academic of fee-for-service reimbursement, and activities. relatively robust federal and philanthropic funding for basic science research. It was Autonomy and authority are primary val- also an era when both basic and clinical ues that have permeated the entire profes- sciences developed largely through differ- sion. Historically, non-academic physi- entiation and sub-specialization. It can be cians carried and structured these values argued that the traditional faculty-centered into their work environments by setting departmental structure was a rational and up solo or small, single specialty group effective organization by which biomedical practices, setting their own hours and science and medicine could make signifi- career goals, developing informal patient cant strides in such an era. 11 But both the game and the playing field In the basic sciences, the causes of stress have now changed. on the departmental structure are of somewhat different origin. It is largely the In clinical care, we have already charac- progress of science itself that has begun to terized the most disruptive changes. break down previous divisions between Public policy and market dynamics have disciplines. The convergence of biomed- forced all providers and provider organi- ical science around the methods of cellu- zations to become far more market-cen- lar and molecular biology has made these tered. In health care, as in other service methods relatively ubiquitous. Therefore, industries, the market demands quality over the last decade, the importance of services at a competitive price. This departmental affiliation in differentiating requires that service organizations have an basic science faculty has diminished. entrepreneurial and competitive spirit, Departments are becoming more alike in and demonstrate their ability to meet cus- the questions being addressed, in the sci- tomer (here patient and increasingly pur- ence being applied, and in the training chaser) needs. being provided. Also serving to loosen these structures are collaborative service Few would disagree that, while some laboratories needed to perform analyses departments are adapting better to the such as high-end computation. Even demands of the market than others, taken though academic advancement still together, clinical departments of AHC requires investigators to demonstrate medical schools have been reluctant independence and originality, cross-disci- change agents. Departments were not plinary and cross-departmental collabora- designed to enable more than relatively ad tion have become routine, if not neces- hoc and contingent forms of cross-depart- sary, for successful work. ment or cross-disciplinary cooperation in either their service or their academic Yet, while academic departments are missions. Despite significant efforts to under great strain, they continue to have integrate many administrative functions relevance and to serve important func- within integrated faculty practice plans, tions in structuring and protecting the clinical departments continue to pose academic life of faculty, in education, and barriers to improving clinical operations in the organization and administration of and implementing delivery innovations. many other institutional goals. And many As a result, the marketplace (and by external systems and structures remain in proxy, usually the medical school dean) place that make departmental divisions is causing unprecedented stress on the still important. Among these are academic departmental structure by asking it to and professional societies and journals, as pursue goals and undertake functions for well as public and private research fund- which it is not designed. More than one ing agencies, many of which still look to commentator has remarked that the clini- support work initiated within specified cal department chair’s job is becoming disciplines by individual investigators. almost untenable (Korn, 1996; Aschenbrener, 1998). 12 The challenge for AHCs, therefore, is to • Ensure the integrity and continuing viability of individual basic science departments by pre- develop new organizational arrangements, serving their roles in the administration of systems, and processes that can: research and education programs; and • Draw from and strengthen important academic • Create a new mechanism through which and administrative roles traditionally played by departments can align their interests and the departments; and optimize their resource utilization and performance in the pursuit of common goals. • Overcome departmental barriers and enable the appropriate organization of faculty to meet This was accomplished by a strategy that pressing new missions and goals. included: A survey of such efforts suggests some principles and approaches that can guide • Strong leadership in building a consensus among chairs and departments for the need leaders in the effort to reform with and opportunity to pursue such a model; change. • Establishing an organizing mechanism – the PIBS Executive Committee – made up of all Change in Research basic science chairs and elected faculty members; The Program in Biological Sciences (PIBS) • Centralizing faculty recruitment, admissions, at the University of California San curricular, and core facilities responsibilities Francisco (UCSF) Medical School repre- largely with the PIBS Executive Committee; sents one approach to reforming organiza- tions around research. The PIBS was cre- • Securing departmental control over their full-time employees or FTEs, space, appointments, and ated in 1985 to leverage the promotions; and methodological convergence in the basic biological sciences. UCSF concluded that • Making each department the home of one or more research or graduate program, so that progress might best be achieved through multidisciplinary research and graduate training programs rather than departments. The programs continued to be administered by goal was a new organization that would individual departments as a resource for all departments. not replace the departmental structure, but overlay it with a research and training organization that would enable faculty The result is an organizational structure and students to easily cross departmental that reinforces mutual incentives and boundaries to pursue work and collabora- reciprocal responsibilities (see Figure 1). tion. The PIBS has been very successful It is a model that enables faculty to coop- and UCSF is currently developing an erate to achieve common and converging entirely new biomedical sciences campus goals. It allows for small new teams of tal- and pursuing clinical reorganization ini- ent to develop new programs and projects tiatives based on this model. that can function as new “businesses” within the larger organizations. The Extrapolating from this effort, the princi- important roles of the departmental struc- ples most important to the success of this ture are maintained for faculty. model appear to have been to: Department chairs are empowered to address both departmental and broader institutional goals. Students have access 13 to the entire basic science faculty for Also becoming more widely understood is research and doctoral work. But larger the prevalence and impact of chronic dis- perspectives are possible and new “micro- ease on population health status and on organizations” can also form and flourish. health care costs. Chronic conditions affect almost half the population and account for a majority of health care costs (Hoffman et al., 1996). Both professionals Figure 1: and the public are increasingly aware of Anatomy of PIBS Anatomy of PIBS the inadequacy of fragmented and episod- ic care for the management and treatment PROGRAM EXAMPLES of chronic illness or disability (Wagner, Departments Developmental Biology Faculty Recruitment 2000). The recent Medical Expenditure Panel Survey (MEPS) of the Agency for Anatomy Structural Biology New Programs Healthcare Research and Quality (AHRQ) Genetics Admissions and the National Center for Health Biochemistry Immunology PIBS Curriculum Statistics identified fifteen common chronic conditions as the leading causes EXECUTIVE Microbiology Cell Biology COMMITEE Retreats of morbidity and mortality in the nation. Pharmacology Neurosciences PIBS “Pizza” These include: cancer, diabetes, emphyse- ma, high cholesterol, HIV/AIDS, hyper- Pharmacogenetics UCSF Fellows tension, ischemic heart disease, stroke, Physiology Opportunity Funds arthritis, asthma, gall bladder disease, stomach ulcers, back problems, Alzheimer’s disease and other dementias, and depression and anxiety disorders Change in Clinical Care (MEPS, 2000). In clinical care, there has been progress in Within AHCs, by far the most well devel- developing new organizations and sys- oped centers for multidisciplinary care are tems that cross departmental barriers. the comprehensive cancer centers. The These primarily involve the development best of these, particularly those that have of “centers” for either disease- or demo- achieved National Cancer Institute (NCI) graphic-specific care. Many AHCs, com- comprehensive cancer center designation, munity hospitals, and other providers are examples of what it is possible to have developed specialized centers for achieve within the AHC environment – cross-disciplinary, comprehensive care. and only within that environment. These include spine, diabetes, eye, mental health, and cancer centers, as well as chil- These centers combine the best in dren’s, women’s, and geriatric health cen- advanced care, research, and training. ters and others. There is growing consen- They bring together expertise from many sus in the provider community that such disciplines, including medicine and sur- centers offer a more patient-centered envi- gery, nursing, nutrition, rehabilitation, ronment than the traditional multi-site, and others. They also bring together a multi-department approach. wide range of diagnostic and treatment 14 resources. They enable faculty and staff to the coordinated systems of care they develop systematic approaches to particu- know would better serve their patients. It lar diseases and customized approaches to is time to break down these barriers. And, individual patients. Teams of care it is time for AHCs to lead the way in sug- providers and staff routinely organize and gesting and pressing for specific policies re-organize to meet various demands and and reforms that will address these barriers. to pursue new courses of research, treat- ment, or training. Patients are accommo- The existing organization of AHC dated and their families are supported by providers and health services in depart- facilities and services centrally and conve- mental units is insufficient for the task of niently located. At their best, they allow organizing and delivering comprehensive new subgroups to develop and pursue disease-focused, patient-centered care. new ideas coming from research efforts And although the departmental model discovered within or external to the may be viable for episodic care, that organization. model cannot support the transition to a value-driven health system that includes These centers are vitally important to population health management. progress in the diagnosis and treatment of cancer nationwide. They are prime exam- It is imperative, therefore, that AHC and ples of patient-centered health services health professions leadership come and a compelling model for similar efforts together to forge, embrace, and aggres- around other chronic diseases. They are a sively advocate a new leadership agenda. leading paradigm for how AHCs can be The Crossing the Quality Chasm report the foundation for progress across their strongly urges major health system stake- multiple missions in research, education, holders to adopt the fifteen leading chron- and care. The most innovative centers are ic conditions identified by the MEPS as constantly looking to leverage new ideas “priority conditions” around which to and technologies, such as the Internet, to focus efforts to re-organize the health sys- further improve patient management and tem. The Blue Ridge Group supports that research activities. Yet comprehensive recommendation. centers like these are not yet the standard approach for delivering complex care. A new leadership agenda must aggressively Why? pursue the expansion of federal support for the establishment of patient- and disease- The most important factors normally centered efforts. It must also pursue reform described are limited federal funding and in public and private reimbursement payor reimbursement systems that do not systems. Payments must be aligned with recognize or reward collaborative care. desired practices and outcomes so that Regardless of other issues and barriers, health professionals and provider organiza- the inability to fund the creation of such tions can transition to more functional centers or to receive appropriate payment structures and organizations. for health services provided within them, severely limit the capacity of health pro- fessionals and organizations to develop 15 Finally, a new leadership agenda must It is not surprising that educational pro- support a dramatic increase in our capaci- grams might take a back seat to other ty to assess, measure, and improve quality mission imperatives. There have been and outcomes in health care. We now strong financial incentives for medical know that discovery of new treatments is schools to encourage and reward faculty not the cure. Research has shown that achievement in research and productivity valuable innovations require, on average, in clinical care. Significant programs for seventeen years before they are picked up funding of biomedical research are provid- and generally applied (Balas, 2001). Even ed through the federal government, phi- then, substantial variations in perform- lanthropies, and the private sector. ance persist. Strong advocacy must be Clinical revenues, in particular, have been undertaken to generate the federal fund- used to cross-subsidize the costs of med- ing resources that can support new ical education. Very few such financial research on quality and outcomes metrics resources, public or private, have ever and the development and application of existed for the direct support or incen- information technology needed to meas- tivization of teaching. ure quality and assure improvement in managing outcomes. A sudden flood of new funding would not be enough to address the need for educa- Change in Education tional reforms. As it has in the other mission areas, the faculty-centered depart- The educational and training missions mental structure has defined and increas- within the AHC are no less in need of ingly limited educational innovation. organizational redesign. Even though the medical school has long been the organi- Until some significant reforms undertaken zational center of the AHC, starting with in the last decade of the 20th century, the Flexner report of 1910, medical most medical school curricula were schools have been regularly criticized for organized into two to three years of large allowing their education programs to take lecture courses in the biological sciences a back seat to other missions. In the followed by one to two years of clinical decades following the establishment of rotations. This structure enabled the vast federal funding for research through the majority of faculty to avoid any teaching National Institutes of Health (NIH) and obligations, and for those with such other agencies, medical schools have been duties or aspirations, to teach only one to criticized for valuing faculty contributions two courses per year. Many “teaching” (and funding support) in research over faculty taught (and many continue to contributions towards medical student present) only one or two lectures per educational goals. In more recent years, semester or per year, with many clinical they were criticized for valuing contribu- teaching duties handled by “voluntary tions (revenue generation) in clinical care faculty” preceptors in the community. over educational service (Ludmerer, 1999). Nevertheless, a critical mass of extremely dedicated teachers developed in all schools. Though sometimes held in less 16 esteem by research-driven colleagues and tion criteria that would weigh teaching passed over for promotion, they have contributions more heavily. managed to structure supportive learning environments. Often spurred by the Just as faculties and departments were national accrediting body, the Liaison pledging a renewal of support for the Committee on Medical Education teaching mission, the market and public (LCME), medical schools have devoted policy tide turned and resources began to the resources necessary to meet and tighten. Deans and departments now exceed traditional professional standards. faced the prospect of having to fulfill significantly increased commitments of In the late 1980s and early 1990s, a med- faculty time and departmental resources ical educational reform movement swept to the teaching mission at a time when medical schools. Medical education, char- they faced increased clinical demands and acterized by the large lecture format and the reduction of departmental financial minimal interaction with faculty, was sub- resources. ject to much critique. Molecular biology was changing and vastly expanding the While new curricula are being imple- knowledge base. Medical practice was mented to favorable reviews in AHCs changing as the new market-driven envi- around the nation, the increased expecta- ronment began to impinge on the organi- tions and resource requirements have zation of care. Gender and cultural issues heightened the strains within and in the delivery of care grew more promi- between departments. Clinical depart- nent. It was no longer enough for medical ments and faculty are affected more than students to learn primarily through mem- those in the basic sciences. Departments orization and recitation. They had to trying to fulfill teaching obligations press become problem solvers. faculty to teach. Clinical faculty who like to teach, increasingly are pressed to The new model developed and adopted by generate revenues and meet clinical many schools was the small group semi- productivity goals and measures. Most nar and problem format. Many large lec- departments struggle with even minimal ture classes were replaced, or more often, teaching time and resource requirements. augmented by small group seminars, jour- Many clinical faculty argue that they nal clubs, and problem-solving sessions. should be separately compensated for The basic science curriculum was time away from the clinic. redesigned to reflect the cross-disciplinary convergence around the new methods of Once again, the limitations of the depart- molecular biology and genetics. Students mental structure are implicated in the also were offered courses on medical problem of meeting mission goals in this ethics, medical economics, and other rele- new era. That traditional departmental vant topics. New clinical rotations were structures would have difficulty with the added in non-traditional outpatient and educational mission might seem surpris- ambulatory settings. Deans and depart- ing. It should not. The educational mis- ment chairs were creating flexible teach- sion must draw on the same constellation ing funds and working to adjust promo- of inter- and cross-disciplinary resources 17 as the other missions. Institutional expecta- Real and necessary change will require tions, environmental factors, faculty com- more. At UCSF a novel program to sup- , mitments, and departmental priorities and port teaching is the Academy of Medical resources are not aligned. Department Educators. The Academy is an interde- chairs, individually or collectively, do not partmental network of master teachers have the real or organizational resources to who are selected by a peer review process. meet the demands of this new environment. Membership in the Academy is a special honor that can be supported by a five year Aligning the teaching function with the endowed chair. The Academy has been research and care missions within the replicated in at least one other AHC and imperatives of the current environment others are studying it. can only be achieved with the proper organization of faculty and resources. The advantage of this approach is that a As with the other missions, this requires new organization is being created and mechanisms for cross-disciplinary and populated by master teachers who will inter-departmental cooperation and represent the best in educational commit- reciprocation. ment throughout the organization. The Academy’s effectiveness will, however, A great many efforts are underway within depend on how it is organized and devel- AHCs as well as among professional and oped. If the Academy develops simply as a industry associations to develop rational faculty-centered network of gifted and responses. Most AHCs have developed dedicated teachers, this approach could special departmental or institutional turn out to be simply another form of teaching funds to provide awards and incentive and reward system, or a new bonus incentives for faculty teaching. institutional mandate competing with tra- Many have developed salary adjustment ditional departments for resources. These and other compensation formulas based outcomes would signal a reform without upon the relative valuation of teaching change. and other mission fulfillment activities (Rouan and Wones, 1999; Sussman et al., To be a reform with change, the Academy 2001). At the same time, the drop in med- will have to develop into an organization ical school applicants and the shifting dis- that involves departmental leadership and tribution of students seeking post-gradu- that has the power to effect the mar- ate training is causing increased reflection shalling and reorganization of some depart- within the various specialties as they too mental functions and resources into coop- look at their “market” of consumers. erative programs structured to achieve While many of these approaches are student-centered educational goals. extremely laudable and quite sophisticat- ed, most are progeny of the “reform with- out change” approach. Most will fail because they are aimed at reforming the processes of a structure that can no longer support its function. 18 Organizational Innovation Recommendation and Action Steps Recommendation • AHCs should develop and implement approaches to managing the barriers they organizational innovations and programs pose to clinical, research, and that enable faculty and staff to achieve education/training programs. societal health care needs and to create a value-driven health care system. • AHCs should pursue changes in public and private payment systems that will Action Steps eliminate payment barriers and disincen- tives for providers and provider organiza- • AHC leadership should adopt the fif- tions transitioning to practice in such new teen leading chronic conditions identified structures and organizations. by the MEPS as “priority conditions” around which to focus organizational • AHCs should seek federal and other reform efforts. sources of support for needed research and the development of quality and out- • AHC and other provider health sys- comes measures and the application of tems should support the development of information technology to quality and out- comprehensive disease- and/or demo- comes management improvements. graphic-centers of care on the model of the NCI Comprehensive Cancer Center • AHCs should lead efforts to demon- designation. strate the value of organizational restruc- turing on health care and health status. • AHCs should systematically review the roles of existing academic departmental structures and develop new organizational 19 Enabling Knowledge Workers Optimizing Performance For more than a century, social scien- As a result, affected individuals or classes tists, and more recently, business manage- of individuals essentially lose their way. ment experts, have studied the effects of They lose their motivation. They lose the organizational change and dislocation and frame of reference necessary to solve have developed sophisticated models of problems, or even define success. They process and personnel management. become discouraged and disillusioned. At French sociologist Emile Durkheim laid the extreme, they commit suicide. In an the foundation for this work at the turn of earlier work, The Division of Labor in the 20th century. Durkheim wrote a path- Society, Durkheim identified anomie as a breaking treatise on a major and growing problem inherent to the ever-changing, fact of modern societies, the phenomenon increasingly complex division of labor of suicide. He described a new schematic and fragmentation of traditional commu- of causes of suicide in modern societies nities in modern societies (Durkheim, and introduced, among others, the con- 1964). He went on to suggest that a criti- cept of “anomic suicide” (Durkheim, cal role for society, including leaders in 1966). Durkheim described anomie as a government, industries, and all profes- condition of personal dislocation and anx- sions, was to develop common goals iety often caused when social conditions (based on humane values) and systems by (usually social or economic upheaval) which affected individuals and groups cause individuals or classes of individuals could renew and sustain the motivation to to lose their sense of the importance or understand and contribute in times of sig- value of their contributions to society. nificant change (Blue Ridge Academic Traditional values and definitions of suc- Health Group, 2000). cess are called into question. New values and normative expectations are not yet well defined and may be years or decades from full social articulation and codification. The principle academic resource of a university is its faculty. – James J. Duderstadt, A University for the 21st Century, 2000 20 Through successive waves of technologi- cal, organizational, and marketplace Exhibit 4: changes during the 20th century, most The Knowledge Worker industries, companies, governments, and “An ever-growing percentage of people are ‘knowledge organizations of any significance have workers’: information and knowledge are both the raw developed in-house human resource and material of their labor and its product ... It’s not only that organizational management capabilities. more people do knowledge work; also increasing is the knowledge content of all work, whether it’s agricultural, blue Catalyzing, organizing, and responding to collar, clerical, or professional. A physician today, armed the many human resource challenges of with antibiotics, magnetic-resonance images, and microsur- change has become a significant core gical techniques brings far more knowledge to his work competency; however, neither the medical than his pre-World-War-II predecessors, whose principal tools were boiling water and a kindly manner.” profession nor universities and their aca- From Intellectual Capital: The New Wealth of Organizations, demic health centers have kept pace with T.A. Stewart, 1997, p. 41. the development of such capacities. Academic faculty, especially AHC faculty, have pursued academic and service func- tions in a relatively protected, self-regulat- ed, and unchanging environment. They have operated with relative autonomy in host institutions under well-established and stable systems of academic and pro- fessional conduct, expectations, and goals. With the changed health care environ- ment, universities and their AHCs can no longer operate as simply host institutions. They are now like other large and com- plex organizations that must support and manage system-wide change involving large numbers of professionals and staff. AHCs must quickly learn, and incorporate as a core organizational competence, the art and science of managing the “knowl- edge worker” (see Exhibit 4). 21 The university and the AHC are the para- • Productivity of the knowledge worker is not – at digmatic employers and creators of knowl- least not primarily – a matter of the quantity of output. Quality is at least as important. edge workers. Most of the organizational structures within these institutions, • Finally, knowledge worker productivity requires including the traditional departments, that the knowledge worker is both seen and treated as an “asset” rather than a “cost.” It have been extremely well adapted for requires that knowledge workers want to work knowledge work. Two distinguishing char- for the organization, in preference to all other acteristics of these professionals are that opportunities. they are self-directed and motivated, pro- vided they have an opportunity to apply Drucker starts with the question; “What their knowledge effectively. Unlike manual is the task?” because, unlike manual laborers or other “directed” workers, they work, where the task is given and obvi- expect their work to be defined not by its ous, in knowledge work, the task often is quantity or its costs, but by its results not obvious to anyone except the relevant (Drucker, 1996). They are best employed knowledge workers. Having responsibility and managed as “associates” rather than for defining the tasks, including how the “subordinates” – the way a conductor work should be done, enables and moti- directs an orchestra. Following Durkheim’s vates knowledge workers to take respon- early observations, contemporary research sibility for structuring effective solutions. confirms that if knowledge workers are mismanaged and lose their sense of being While at first blush, this might seem effective within an organization, they will somewhat utopian or unrealistic, there lose direction and motivation. are innumerable examples of knowledge workers assuming such responsibility Drucker identifies six factors for organiza- with great success (Drucker, 1999). tions and professionals to consider as they However, it might be enough to contem- seek to strengthen knowledge worker pro- plate the differences in productivity and ductivity (Drucker, 1999, p. 142): motivation between a clinical faculty member in a department for whom signif- • Knowledge worker productivity demands that icantly higher clinical output targets have we ask the question: “What is the task?” been set, and a clinical faculty in a • It demands that we impose the responsibility for comprehensive cancer center setting their productivity on the individual workers faced with the same new goals. themselves. Knowledge workers have to manage themselves. They have to have autonomy. In general, faculty measured against departmental productivity targets will • Continuing innovation has to be part of the likely be less motivated than those work- work, the task, and the responsibility of knowledge workers. ing in a more comprehensive clinical care setting. A faculty member in the first situ- • Knowledge work requires continuous learning ation will have few choices but to see on the part of the knowledge worker, and equally continuous teaching on the part of more patients. She or he will have little the knowledge worker. chance of affecting the goals or defining the “task,” and is reduced to reacting as a subordinate, rather than engaging as an 22 associate. A faculty member in the second had to understand and then change and situation will have better opportunities to adapt to new market conditions in all work with colleagues and teams to define three missions. Vitally important to this the task and to refine work processes effort has been the development of new and/or resource utilization to achieve standards and metrics by which faculty institutional goals. She or he will be able can calibrate their expectations and con- to redefine the task in order to achieve tributions – and by which those contribu- higher quality outputs that can affect tions can be measured, assessed, adjusted, financial performance. The faculty mem- and rewarded. Critical to this entire ber treated (however inadvertently or process has been the gathering and organ- indirectly) as a subordinate will not per- izing of data from and about all aspects of form as well as the faculty member able to patient care, education, and research. engage and define the task as an associate and team member. Important lessons can be gleaned from Baylor’s effort about how a change process Clarifying Expectations affects those directly involved. One lesson is that the very process of collecting data Virtually all AHC faculty and staff are can itself be a significant change and knowledge workers. Management of AHC cause significant stress within the organi- faculty is legendary in its difficulty. Even zation. Data collection is not a value-neu- before the era of market-driven change, it tral process. It is an activity that signals was often sardonically described as “herd- and represents important information ing cats.” Now, however, the sardonic about how missions, values, and goals are grins have disappeared and a new sense of being (or are likely to be) redefined. urgency in managing these particular Every new bit of data requested and knowledge workers has taken its place. collected is likely to signal implications Many AHCs have embarked on compre- for the roles and expectations of those hensive programs designed to bring new from, or about, whom the data is collect- management discipline and performance ed or provided. expectations to their faculties (e.g., University of Alabama at Birmingham and It is therefore important to manage the Washington University) (Blue Ridge data collection process as carefully as any Academic Health Group, 1998a). Most other aspect of the change process. AHCs have worked to redefine faculty Affected faculty and staff must be incor- and staff performance goals and metrics porated into, and informed of, the change and realign them with changing environ- process, beginning with the definition of mental and organizational missions and relevant parameters, data needs, and data expectations. collection processes. Baylor has also addressed faculty concerns by ensuring For instance, more than five years ago, that individual faculty data remains confi- the Baylor College of Medicine initiated a dential between faculty and chairs, with process of faculty evaluation. The effort only departmental-level data shared with stemmed from a strategic plan initiated deans or the board. out of the realization that the organization 23 The Baylor initiative has led to the devel- AHC management and productivity opment of a sophisticated set of financial enhancement measures that fail to ade- metrics used to measure effort, contribu- quately develop and factor-in quality met- tion and success in each mission area (see rics, however, may be fated to fail. Most Appendix 1 for an in-depth description of are likely to be only minimally effective in these metrics). These and similar meas- orchestrating the change and performance ures have been developed by other AHCs, required. Baylor has taken the position many with the assistance of consulting that there are core metrics that help chairs firms, like Cap Gemini Ernst and Young and deans to lead and manage, recogniz- (CGE&Y). These metrics are necessary ing that certain individual contributions and important tools that promote align- are best assessed qualitatively by the rele- ment of faculty and staff efforts with new vant chair or supervisor (Garson, 1999). market realities. Measuring Quality and Nevertheless, despite a great deal of facul- Outcomes ty participation in the development of such metrics, Baylor and all other AHCs In clinical care, quality and outcomes report significant faculty dissatisfaction measures incorporated for faculty evalua- with them. Although still early in the tion are often limited to patient satisfac- process, common complaints are that they tion surveys. These are helpful and useful, epitomize the “commoditization” of but are only a first step in capturing, health care and diminish the status and quantifying, and measuring the quality role of the health professional in the care and outcomes of care. Since quality and process (Johns and Niparko, 1996). While outcomes are what matter most to the they quantify and enable measurement knowledge worker, it is absolutely critical (often for the first time) of faculty and that such measures become integral and staff productivity and its financial impact, primary in faculty commitment and evalu- these measures may be limited by what ation metrics. The first report of the Blue they measure accurately as much as by Ridge Group provides sample recommend- what they do not measure accurately. ed performance measures for AHCs that Most difficult to assess are measures of include measurements of quality, innova- the quality and outcomes of faculty and tion, and societal value (Blue Ridge staff effort along each mission focus. Academic Health Group, 1998a). For faculty, professionals, and knowledge Understanding that the current status of workers in general, who have high and development of such metrics is universally very specialized levels of expertise and acknowledged to be rudimentary, how can knowledge, judgments and measurements this problem be addressed? The first step, of quality are usually the most important as Drucker suggests, is to ask the ques- metrics. Admittedly hard to quantify, they tion: “What is the task?” If the task is to are nevertheless routinely acknowledged understand how to measure and evaluate and measured by peer respect and esteem. quality and outcomes of clinical care, then 24 It is important to remember that the conduct. It simultaneously system for measuring success in any influences, and is influenced by, organization has evolved over many every part of the organization. years. It is as much a part of an – Peter Senge et al., organization’s “culture” as are styles The Dance of Change: The Challenges to of dress and unquestioned norms of Sustaining Momentum in Learning Organizations, 1999 Improving the productivity of knowl- edge workers and service workers will demand fundamental changes in the structure of organizations. It may even require totally new organizations. – Peter Drucker, The Post-Capitalist Society, 1994 25 who is in the best position to answer that purposes of evaluating the quality of sci- question? Primarily, (though not exclu- entific work of candidates for promotion sively) it is the clinical care professional. and hiring. The second step is to give the responsibil- Though understandably difficult to cali- ity of answering this question to the clini- brate precisely and subject to some cians. When asked what quality is, clini- debate, there is growing interest in the cians often respond, “I don’t know how to adoption of this, and related quality met- explain it, but I know it when I see it.” If rics in the United States (Holmes et al., they are not motivated to go beyond that 2000). Since scientists, too, will claim to explanation, then their clear knowledge of know quality when they see it, efforts to what constitutes quality will remain with- quantify and make such knowledge acces- in the knowledge base shared by their rel- sible seem a reasonable and important atively small group of professional peers. project to shore-up a new focus on knowl- If, however, these clinicians are teamed edge-worker support and management. with other knowledge workers who are experts at developing metrics for intangi- Equally important is the acceleration and ble measures, progress can surely be expansion of quality and outcomes met- made. As simple as this might sound, rics for teaching faculty. A variety of met- these two steps have yet to be taken seri- rics exist, including, but not limited to, ously. They should be. student evaluations, peer review through observation and review of pedagogical In research, quality and outcomes metrics methods, performance of students on are better grounded. They are embedded standardized tests, and scholarly contribu- within the peer-review process that serves tions in the field and in the development as the foundation for awarding research of pedagogical methods. support to investigators. There is also, within each field of research and scholar- Yet, broadly accepted standards by which ship, a hierarchy of journals, invited lec- to measure relative strengths of faculty in tures, and other forms of “publication” teaching are lacking (Blumenthal, 1997). that assess contributions along the hierar- This gap exists because teachers face a chy. This is a firm foundation, though moving target. Student populations more can be done. change over time and present different learning needs. Content requirements are For instance, over many years in Great constantly evolving and new technologies Britain, a complex bibliometrics algorithm create new pedagogical opportunities. has been developed and continually Moreover, comparisons across disciplines refined, which assigns weighted values to are complicated. Different subjects, all professional publications. This effec- departments, and schools attract students tively creates a hierarchical ranking based with differing abilities, motivations, on reputation. The publishing record of demographics, prior preparation, and individual scientists and faculty in the experience. Additionally, the development universities is tracked and weighted by of standardized metrics is impeded by these metrics and can be accessed for the limitations on access to needed data. 26 For instance, a leading researcher and his The General Electric Company (GE) is a collaborators, conducting research on global corporation with dozens of enter- training outcomes and quality, asked all prises in hundreds of locations around the specialty certification boards for data on world (Lynch, 2001). During Jack Welch’s their board certification examination pass 30 year tenure as Chairman and CEO, GE rates. All but one specialty board declined grew from a $28 billion to a $130 billion or failed to provide this information. company. The vast majority of GE’s Analysis of what limited information was 350,000 person workforce consists of obtained raises a range of important ques- knowledge workers, some of whom are tions about training outcomes that, among dedicated research scientists, engineers, other things, could aid in developing and high technology professionals. The quality and outcomes metrics that could challenge of managing this large, diverse, be applied to evaluating, designing, and international workforce is daunting. improving clinical training (Blumenthal et While much about the GE situation is not al., 2001). In education, as in clinical care directly analogous or applicable to AHCs and research, significant progress in today, there are a number of knowledge developing quality and outcomes data and worker management practices and metrics is both possible and essential. policies that deserve emulation. AHC, academic society, and health profes- GE considers its dedication to “People, sions leadership must become the leading Processes and Performance” as key to its advocates for the development of quality success. These three elements are driven and outcomes metrics in every mission through the organization by a strong area. Renewed federal funding for leadership process that continuously research and development of such metrics evaluates, articulates, and then reinforces is essential. The full cooperation of all organizational priorities and values. The academic, professional, and institutional organization is defined by the need to stakeholders in accommodating such constantly drive change so that it is research and development is also essen- always seeking and creating new growth tial. For example, all certifying boards opportunities. Change is driven through a should publish their board pass rate data combination of organizational structures by program, as has been the policy of the and processes built around: American Board of Internal Medicine since 1996. • Hiring great people • Creating a performance culture Bringing Good Things to Life • Linking results with rewards • Demanding shared values We spend all our time on people. The day we screw up the people thing, this • Believing everyone counts company is over. Jack Welch, CEO, GE Professional and leadership development are primary functions of the organization and new talent is constantly sought after 27 and aggressively recruited. Continuous Since GE puts such significant resources learning, performance appraisal, and feed- into developing the capabilities of its peo- back mechanisms are built into the work ple, it is also keenly aware of the cost of schedule and process. These activities losing those people, whether to competi- occur at every level of the organization. tors or to unrelated industries. Therefore, Major milestone meetings are scheduled GE makes what some might consider up to a year in advance and attendance is extraordinary efforts to ensure that the mandatory. This embedded management feedback loop runs in all directions and process also serves as a way to connect that its people feel like they and their people throughout the organization and families matter in the organization. for continuous communication “bottom- Special programs, gifts, dedicated services, up and top-down.” and communications all play an impor- tant role in building a relationship not just to the worker, but to the person. The most valuable asset of a 21st Century institution, whether business No doubt, this is a high intensity environ- ment. The pressure to perform, to dedi- or non-business, will be its knowl- cate oneself to the organization’s values edge workers and their productivity. and goals, to meet and exceed objectives, is unrelenting. Individuals have to work – Peter F. Drucker, Management Challenges for hard to balance competition and collegial- the 21st Century, 1999 ity, and personal and professional obliga- tions. Nevertheless, employee retention is extremely high and people are seldom Critically important to their enterprise is summarily dismissed. The ongoing evalu- that everyone in the organization knows ative process enables the organization to exactly what is expected of them, which identify issues or areas in need of metrics are being used, and why, and how improvement early, so that individuals they are measuring up. People are put at have the opportunity to work on them risk and held accountable for certain com- and improve. mitments and they share amply in the rewards for reaching the objectives. High- While the goals and some of the values at level performance is generously rewarded a global corporation like GE may not through pay and promotions. Continuous align completely with those of an AHC, feedback and learning, and ongoing eval- the need to manage and motivate knowl- uation create highly motivated people edge workers is highly analogous. The GE with the tools to meet and exceed expec- example illustrates how it is possible, tations. Collegiality, flexibility, the ability with the appropriate organizational struc- to work with and motivate others and to tures and personnel management policies make good decisions are all highly valued and processes, to motivate extraordinarily and rewarded. People are regularly moved large and diverse organizations of knowl- and promoted and new teams are created edge workers to maintain high levels of to meet new opportunities. performance. It also illustrates how dedi- cating organizational resources to the 28 development of people can sustain moti- vation even when policies or processes sometimes fall short. In the AHC, and in universities more gen- erally, there is nothing like this level of resource commitment or organizational focus for the purpose of supporting faculty and staff in their professional development and in their work. For the healing profes- sions to attract and retain the best and the brightest in the future, it has no alternative but to adopt many of these proven meth- ods. The example of GE and hundreds of other companies and organizations offer a clear example for AHCs now struggling with the imperatives of the marketplace and with motivating an increasingly unset- tled knowledge workforce. 29 Enabling Knowledge Workers Recommendations and Action Steps Recommendation Recommendation • To enhance value-creation, motivate • AHCs should develop new and performance, and improve quality and improved human resource capabilities that outcomes, AHCs must develop a new enable routine performance appraisals, understanding of knowledge workers and identification of new talent, cultivation of the types of organizational systems and skills, and mentoring of faculty and staff. processes required to manage and lead them. AHCs should commit to ongoing Action Steps leadership, professional, and staff develop- ment as an integral part of each mission. • AHCs should experiment with policies that motivate faculty through the distribu- Action Steps tion of risk and reward. • AHCs should build upon proven lead- • AHCs should develop enhanced tools ership and management approaches and for measuring performance of the system human resources development programs, and individuals (i.e., metrics) to promote like those of GE, that align with the way accountability. highly skilled knowledge workers are properly supported and motivated. • National organizations, such as the Association of American Medical Colleges • AHCs should re-evaluate accepted (AAMC), Association of Academic Health measures of performance and value on Centers (AHC), or Institute of Medicine an ongoing basis, and identify ways to (IOM) should conduct or sponsor studies enable faculty to better manage their of enhanced Human Resources capabili- roles, responsibilities, and expectations. ties and infrastructure for AHCs. AHCs must develop more sophisticated measures of value creation to guide the organization, direction, and evaluation of institutional and personnel performance. • AHCs should ensure that all faculty and staff in management and supervisory positions are provided training and sup- port in the delivery of regular performance feedback and the development and men- toring of professionals. 30 Overcoming Cultural Barriers Developing New Archetypes A final critical dimension of the AHC and figures in the history of medicine akin to health professional organization that must Bobby Knight or Woody Hayes of college be reformed and realigned is the culture coaching fame. The indomitable personal- of the organization. The AHC and the ity is one whose combination of brilliance medical profession have traditionally been and independence of thought and eccen- supported by three cultural archetypes. tric (or worse) behavior are not tolerated or compatible with most organizations or The first is the ideal of the independent institutions. In academia the combination and original investigator. For the doctoral has been, not only tolerated, but often degree and for academic and professional rewarded by a series of increasingly senior advancement, the individual candidate and prestigious appointments at a succes- must demonstrate independence of sion of leading universities. thought and originality of achievement. The training of students and career trajec- Each of these three academic archetypes, tory of faculty are effectively defined by like the organization and management the requirement to distinguish oneself and systems they support, is under consider- one’s work from that which preceded it able strain. How these archetypes are and to show originality relative to the addressed will determine a great deal work of one’s peers. about the viability of the change in the AHC and professional organization. The second archetype is the “triple threat” faculty physician. This is a high energy individual who is a great clinician, a solid, if not brilliant, investigator, and an inspir- ing teacher and mentor. The triple threat Culture is not something that you has long served as both an ideal and an idol manipulate easily. Attempts to grab it by which clinical faculty or physician scien- tists could calibrate their efforts and by and twist it into a new shape never which their contributions could be valued work. Culture changes only after you and measured for the purposes of career have successfully altered people’s advancement and academic promotion. actions, after the new behavior pro- The third archetype, less universally duces some group benefit for a peri- admired, but nevertheless widely accepted od of time, and after people see the and cultivated within academia (and aca- connection between the new actions demic medicine in particular), has been and the performance improvement. the strong, independent, charismatic, ego- centric, and often authoritarian or highly – John P. Kotter, maverick personality. These characteris- Leading Change, 1996 tics are often associated with legendary 31 The first archetype, independence and medical schools and faculties, the grounds originality, is being tested by both internal for promotion and advancement broad- and external factors. Internally, as we ened and became more flexible. New have described, the methodologies of sci- thinking has challenged the conventional ence, and perhaps of important clinical view of scholarship and has contributed and educational processes, are converging. to the development of a more sophisticat- Faculty seek out collaborators across the ed understanding of the value of several entire spectrum of research, clinical care, forms of scholarly activity (Boyer, 1990; and educational programming. Externally, Angstadt et al., 1998; Nora et al., 2000). public and private funds are increasingly At the same time, AHCs and medical seeking to maximize return on investment schools have developed along a variety of by choosing to support work that can paths, with different emphasis on clinical draw on multidisciplinary sources of care, education, or research. The relative expertise. More and more progress in sci- value or importance of these characteris- ence, medicine, and education is occur- tics and contributions now vary by insti- ring as a result of cross-disciplinary and tution and by department within institu- cross-institutional collaboration, whether tions. Consideration of academic episodic or long-term and continuous. advancement normally depends upon External factors also include market- excellence in at least one mission area and based pressures that drive the need to substantial contributions in another. reduce costs and create efficiencies in each mission area, including the need to The external forces threatening the triple maximize sharing of core facilities, instru- threat archetype have been even more ments, and other critical resources, as daunting than the internal forces. As the well as knowledge. market-driven environment imposes itself on the AHC and health care, the neces- Clearly, progress in science, care, and sary focus on faculty productivity and rev- education will continue to require inde- enue generation has undermined this gold pendence and originality. So this under- standard. Administrators and faculty alike pinning cannot be allowed to crumble; face the increasing realization that the however, it is also clear that teamwork triple threat no longer serves as a realistic and collaboration are, and increasingly standard by which to measure the value of will be, vital to scientific progress. It is clinical faculty. For increasing numbers of therefore necessary to reform the arche- clinical faculty, clinical productivity, in type so that it holds up both the develop- particular, is becoming a de-facto proxy ment of the independent and original for the value of their contributions as investigator, and the demonstrated ability faculty members. to work collaboratively. Nevertheless, the existing departmental Internal and external forces are also structures and their policies largely have challenging the second archetype, the yet to incorporate this new reality. triple threat (Pellegrin and Arana, 1998). Department chairs, deans, and peers con- Increasingly, as people of diverse back- tinue to send mixed and conflicting grounds and interests began to fill out messages about standards for faculty 32 performance. Tenure and promotion stan- dards, particularly at the elite, research- centered AHCs, overwhelmingly retain the traditional triple threat as an evalua- tive gold standard. Yet, specialization in one mission area with substantial expertise and contributions in another is becoming the new real standard. This new model is more compatible with the progress of science and medicine and with the likeli- hood of ongoing success within academic and professional organizations. While still representative of the highest attainment in the minds of some, the tra- The academy takes great pride in ditional triple threat is becoming more functioning as a creative anarchy. like an ideal than a real standard for the vast majority of faculty and schools. – James J. Duderstadt, A University for the 21st Century, 2000 AHCs and the health professions should cultivate a new triple threat valued and rewarded for: • Excellence in scholarship and/or achievement in one or more of the core academic mission areas: student-centered education, discovery- centered research, or care-centered research or innovation. • Excellence in achievement and/or leadership in the core service mission: patient-centered care. • Excellence in achievement and/or leadership in community, professional, and institutional service to measurably meet societal needs and aspirations for our health care system. A triple threat built on standards like these would be a worthy successor to the former ideal. 33 The final archetype, ego-centrism with (ABIM) is a model of what professional independence of behavior, is also under societies can do to promote a new, more severe stress. Internally, deans and senior adaptive culture for 21st century health administrators, not to mention depart- care. Established in 1992, the Project mental and other affected faculty, increas- developed an enhanced definition of pro- ingly worry about the extent to which fessionalism that has been adopted by the intense competition among AHCs to ABIM. It identified eight elements of pro- recruit stellar individuals is both costly fessionalism to be required of candidates and, in many cases, extremely disruptive. seeking specialty certification: altruism, Recruitment packages can run into mil- accountability, excellence, duty, service, lions of dollars in commitments. honor, integrity, and respect for others. Recruiting high profile individuals and Also identified were seven issues that providing them with outsized and bounti- diminish professionalism, including: ful resources, can be disruptive to depart- abuse of power, arrogance, greed, misrep- ments and even to whole institutions. resentation, impairment, lack of conscien- Very often, appointments of stellar individ- tiousness, and conflict of interest. Project uals to chairmanships and institute direc- Professionalism then developed a program torships have been made without regard to that includes guidelines, forms, and other the leadership or managerial capabilities of materials by which graduate medical edu- the individual. Five years later, the return cation program directors and others learn on this investment can end suddenly as the to mentor and assess residents and candi- star is recruited away by a new high bid- dates for certification. The ABIM project der. Meanwhile, rising stars within the is playing an important role in the formal organization leave, or are recruited away, to incorporation of humanistic qualities into pursue other opportunities. the components of clinical competency (American Board of Internal Medicine, External forces eroding this part of the 2001). culture are the same market forces affect- ing the others. The new environment Leadership Development favors organization and leadership that engenders commonality of purpose and The General Electric Company and many optimal knowledge worker and system other enterprises, both large and small, performance. Independence and originali- have a very different view of leadership ty of thought, the capacity to create team- development and succession planning. work, inspire loyalty, and manage per- They believe that routinely bringing in formance are increasingly prized and new leadership from the outside, as many rewarded. Ego-centrism, authoritarianism, enterprises do, is often more disruptive and independence of behavior are no than successful. longer adaptive. They are increasingly counterproductive. At GE, leadership development and suc- cession planning are top priorities. The The “Project Professionalism” of the idea of routinely recruiting top leadership American Board of Internal Medicine from outside the company is an anathe- 34 ma. Rather, they focus on developing that faculty and staff leadership development leadership from within. They recruit programs and integrated into departmen- individuals with high achievement and tal and other administrative unit opera- leadership potential and then invest years tions and functions. of learning and support to help ensure that they develop it. Individuals sought External recruitment for high leadership must be strong and able to demonstrate positions need not be discontinued. key attributes: independent thought, abili- National and international searches for ty to manage individuals and inspire per- the best individual or team to fulfill a spe- formance, and a talent for building suc- cific leadership or other significant role cessful teams. Individuals displaying are effective. AHCs will, however, likely arrogance, and the penchant for inspiring experience vast improvements in their resentment, mistrust, jealousy, and other organizational and leadership capabilities de-motivating behaviors are either educat- to the extent that such searches increas- ed or weeded out. Leaders are cultivated ingly reveal that the best candidates are to throughout the organization and are be found, because they have been culti- groomed for what they, their supervisors, vated, within their own institutions. and their peers determine together are the appropriate leadership positions. AHCs can no longer afford to reward ego- centric and authoritarian personalities, who cannot manage people or processes well. The environment and the organiza- tion can no longer support this. AHCs must build a new cultural arche- type that supports stellar, brilliant individ- uals with strong personalities who can lead change and inspire confidence and performance among knowledge workers and peers. This new cultural archetype can be built by developing a new focus on leadership development and succession planning for key positions throughout the organization, especially department chairs, deans, and other senior adminis- trative and business managers. Recruit- ment objectives for younger faculty should be revised to include criteria for the iden- tification of potential future leaders. Such internal and occasionally external recruit- ment policies should be aligned with 35 Overcoming Cultural Barriers Recommendations and Action Steps Recommendations Action Steps • AHCs and health professional organi- • AHCs should establish leadership zations should actively work to reform their development and succession planning cultures and archetypes of desirable programs that identify and develop the behavior. new leaders in health care and biomedical sciences necessary for creation of a • AHCs should supplement the culture health care system for the 21st century. of the independent investigator with a cul- ture that supports demonstrated ability to • AHCs and health professional societies establish and be a significant contributor should adopt, as a model set of profes- to, or leader of, fruitful and meaningful col- sional standards, the elements of the laborations and teams. enhanced definition of professionalism developed by the ABIM through its • AHCs should supplant the traditional “Project Professionalism.” ideal of the “triple threat” with one that emphasizes: • Excellence in scholarship and/or achievement in one or more of the core academic mission areas: student-centered education, discovery- centered research, or care-centered research or innovation. • Excellence in achievement and/or leadership in the core service mission: patient-centered care. • Excellence in achievement and/or leadership in community, professional, and institutional service in measurably meeting societal needs and aspirations for our health care system. • AHCs should replace the archetype of the ego-centric, authoritarian, or otherwise organizationally dysfunctional personality and cultivate a new standard that values the stellar, brilliant individual with a strong personality who leads collective change, inspires confidence, and motivates per- formance among peers, other knowledge workers, and staff. 36 Conclusion A new kind of health system is on the and organizational reforms that seek to horizon. It is the responsibility of the truly change organizational performance. entire health community to make progress AHCs should prepare for forthcoming toward the health system of the 21st cen- changes by ensuring that their organiza- tury. Unlocking the promise of the new tional structures foster flexibility and col- system will demand new ways of think- laboration. AHC organizational processes ing, new modes of working, and new should support faculty and staff through kinds of skills for both professionals and clear expectations and robust human organizations. Optimal performance in resource functions. AHC culture, particu- the evolving system will require that the larly its archetypes, should be updated to external environment support health care reflect contemporary needs of AHCs and organizations through reimbursement and the health community. funding mechanisms that reward quality care and create a national health informa- The Blue Ridge Group also believes that tion infrastructure. In turn, health care AHCs should be leaders in building a organizations must support their staff by value-driven health system for the 21st creating an organizational culture and century. This leadership can take a variety structure that enable individual and insti- of forms. AHCs can lead by example tutional excellence. through their organizational change efforts. AHCs can lead by conveying the The Institute of Medicine has provided a new vision to audiences throughout the rallying point for the entire health care health community. AHCs can help shape system and particularly for AHCs and the health policy agenda and decisions health professionals as they seek to define that will in turn determine how well the a sound way forward. By focusing the external environment supports health public policy spotlight on the inadequacy organizations and professions in the new of existing delivery systems and system system. AHCs can use their research goals, and in building on the knowledge, resources to translate the vision into prac- skills, and dedication of the healing pro- tice by expanding knowledge about what fessions, the IOM has articulated clear constitutes safe, effective, and efficient and powerful goals that both health pro- care. Equally important, AHCs can help fessionals and our public can embrace. It current and future professionals acquire is now up to AHCs and their partners the skills they need to achieve excellent within the health community to take tan- performance consistently. gible steps towards transforming the vision of a 21st century health system Absent strong leadership from AHCs and into a reality. professional societies, the continuing tur- bulence in health care also threatens the The Blue Ridge Group believes that AHCs pipeline of bright, idealistic young people should begin by assessing their mission, willing to choose a career in health care. goals, and performance against the goals The pool of medical school applicants and for the new system. Where gaps exist, the ratio of applicants to those accepted there are opportunities for realignment continue to drop (AAMC, 2001). Nursing 37 and medical technician shortages abound. AHCs need to support organizational and cultural changes with comprehensive reforms in the entire spectrum of health professions education – a subject that the Blue Ridge Group will address in a future report. The last several decades have been a time of great turbulence and stress for AHCs and health professionals. Now the health community stands at the beginning of a new era, one that could prove to be momentous for the health and history of the nation. It is essential that AHCs not only prepare themselves to succeed in the future environment, but to define it. 38 About the Blue Ridge Academic Health Group The Blue Ridge Academic Health Group States. Other participants are invited to seeks to take a societal view of health and Blue Ridge Group meetings to bring addi- health care needs and to make recommen- tional expertise or perspectives on a spe- dations to academic health centers to help cific topic. them create greater value for society. The Blue Ridge Group also recommends pub- Blue Ridge Group members collectively lic policies to enable AHCs to accomplish select the topics to be addressed at annual these ends. meetings. Criteria for selection of report topics include relevance to AHCs’ opera- Three basic premises underlie this mis- tions, consistency with AHCs providing sion. First, health care in the United value to society, the likelihood of being States is experiencing a series of transfor- able to make specific recommendations mations that ultimately will require new that will lead to productive action by approaches in health care delivery sys- AHCs or other organizations, and the tems, education, and research. Second, ability to frame useful recommendations the recent upheavals in health care have during two-day meetings. been largely driven by financial objec- tives. Yet the potential exists for funda- Before each meeting, an extensive litera- mental changes in health care to improve ture review is conducted. During the health and manage costs. Analysis and meeting, participants reflect on emerging evaluation of the ongoing evolution in trends, share experiences from AHCs, and health care delivery must address this hear presentations on specific issues. Most impact on the health of individuals and of the working session is dedicated to a the population, as well as on cost. Third, discussion of what AHCs can and should AHCs play a unique role in the U.S. be doing in a particular area to achieve health care system as they develop, apply, visible progress, or a discussion of what and disseminate knowledge to improve public and private policy and philanthrop- health. In so doing, they assume responsi- ic organizations can do to facilitate the bilities and encounter challenges other efforts of AHCs to fulfill their societal mis- health care provider institutions do not sion. The results of the group’s delibera- bear. As a result, AHCs face greater risks tions are presented in brief reports that are and opportunities as the U.S. health care disseminated to targeted audiences. system continues to evolve. The Blue Ridge Group was founded in March 1997 by the Virginia Health Policy Center (VHPC) at the University of Virginia and the Health Market Unit lead- ership at Ernst & Young, LLP (now Cap Gemini Ernst & Young, CGE&Y). Group members were selected to bring together seasoned, active leaders with a broad range of experience in and knowledge of academic health centers in the United 39 About the Core Members David Blumenthal, M.D., M.P.P. Enriqueta C. Bond, Ph.D. Director President Institute for Health Policy Burroughs Wellcome Fund The Massachusetts General Hospital Professor of Medicine and Professor of Dr. Bond is the president of the Burroughs Health Care Policy Wellcome Fund. She formerly held a Harvard Medical School number of research and administrative positions at the Institute of Medicine, Dr. Blumenthal is director, Institute for National Academy of Sciences; Health Policy and physician at The Department of Medical Sciences, Southern Massachusetts General Hospital/Partners Illinois University School of Medicine; Health Care System in Boston, and the Biology Department at Chatham Massachusetts. He is also professor of College. Dr. Bond also serves on several medicine and professor of health care pol- advisory committees and boards, some of icy at Harvard Medical School. Dr. which include the Council of the Institute Blumenthal previously served as senior of Medicine and the National Center for vice president at Boston’s Brigham and Infectious Diseases, Centers for Disease Women’s Hospital, as well as executive Control and Prevention. She has authored director of the Center for Health Policy and co-authored more than 50 publica- and Management and lecturer on public tions and reports in science policy. policy at the John F Kennedy School of . Government at Harvard. Dr. Blumenthal Robert W. Cantrell, M.D. is a member of the Institute of Medicine Director of the National Academy of Sciences and Virginia Health Policy Center serves on several editorial boards, includ- University of Virginia Health System ing The New England Journal of Medicine, American Journal of Medicine, Journal of Dr. Cantrell is director of the Virginia Health Politics, Policy and Law, and the Health Policy Center. Previously, he was Bulletin of the New York Academy of vice president and provost for the Health Medicine. He serves on advisory commit- System at the University of Virginia. He is tees to the National Academy of Sciences, the former president of the American the Institute of Medicine, the National Academy of Otolaryngology-Head and Academy of Social Insurance, and several Neck Surgery. As a captain in the U.S. foundations. He is currently executive Navy, he served as chair of director for The Commonwealth Fund Otolaryngology-Head and Neck Surgery at Task Force on the Future of Academic the Naval Regional Medical Center in San Health Centers and chairman of the board Diego, California. Dr. Cantrell was also of the Massachusetts Peer Review the Fitz Hugh Professor and chair of the Organization. Dr. Blumenthal is also the Department of Otolaryngology-Head and founding chairman of the Academy for Neck Surgery at the University of Virginia Health Services Research and Health School of Medicine. He also has been a Policy, the national organization of health consultant to the Surgeon General of the services researchers. U.S. Navy and to the National Institutes of Health (NIH). Dr. Cantrell is a member 40 or fellow of 33 otolaryngological societies Michael A. Geheb, M.D. and has taken an active leadership role in Professor of Medicine and Senior Vice many, including the American College of President for Clinical Programs Surgeons, the American Society for Head Oregon Health Sciences University and Neck Surgery, and the American Broncho-Esophagological Association. Dr. Dr. Geheb is professor of medicine and Cantrell received the Mosher Award for senior vice president for Clinical clinical research, has published numerous Programs at Oregon Health Sciences articles, and lectured nationally and inter- University. Dr. Geheb has also served as nationally. professor of medicine, and was the first director and chief executive officer of the Don E. Detmer, M.D. University of Alabama at Birmingham Dennis Gillings Professor of Health System. Prior to that, Dr. Geheb Health Management was associate dean for Clinical Affairs, Director and director of Clinical Services at the Cambridge University Health State University of New York at Stony University of Cambridge Brook University Medical Center. Dr. Geheb is on the Board of Directors of the Dr. Detmer heads the health policy and University Hospital Consortium and the management center within the Judge Executive Committee of the American Institute of Management at Cambridge Board of Internal Medicine. Dr. Geheb is University’s business school. He chairs the co-editor of the textbook Principles and Board on Health Care Services of the Practice of Medical Intensive Care and co- Institute of Medicine and is a board mem- editor for the Critical Care Clinics series. ber of several organizations, including the He also speaks frequently to national China Medical Board of New York, the audiences on health care policy issues Nuffield Trust in London, and the related to academic productivity and American Journal of Surgery. He has financial models for academic clinical authored numerous scientific publica- enterprises. tions. Dr. Detmer earned his medical degree at the University of Kansas after Jeff C. Goldsmith, Ph.D. undergraduate studies there and at President Durham University of England. He con- Health Futures, Inc. ducts his work with the Blue Ridge Group through a professorship at the University Dr. Goldsmith’s consulting firm assists a of Virginia where in the past he served as wide range of health care organizations vice president and provost for Health with environmental analysis and strategy Sciences and University Professor. development. He is a director of Cerner Corporation, a health care informatics firm, and of Essent Healthcare, a hospital management firm, as well as a member of the Board of Advisors of Burrill and Company, a private merchant bank in biotechnology and health sciences. He is 41 currently an associate professor of Neck Surgery at Johns Hopkins. Before medical education at the University of that he was assistant chief of the Virginia. He is a former lecturer in the Otolaryngology Service at Walter Reed Graduate School of Business at the Army Medical Center. Dr. Johns is a University of Chicago. He has also lec- member of the Institute of Medicine, and tured on health services management and the Executive Council of the Association policy at the Harvard Business School, the of American Medical Colleges and a fel- Wharton School of Finance, Johns low of the American Association for the Hopkins, Washington University, and the Advancement of Science. He serves on the University of California at Berkeley. Dr. Governing Boards of the National Goldsmith has served as national advisor Research Council and the Clinical Center for health care for Ernst & Young LLP , of the National Institutes of Health, and was director of Planning and Government on the advisory committee of the director Affairs at the University of Chicago of the Centers for Disease Control and Medical Center, and special assistant to Prevention. He is the president of the the dean of the Pritzker School of American Board of Otolaryngology, editor Medicine. Dr. Goldsmith has written for of the Archives of Otolaryngology-Head and the Harvard Business Review and has been Neck Surgery, and a member of the Board a source for articles on medical technolo- of Trustees of Genuine Parts Company. gy and health services for The Wall Street Dr. Johns received his bachelor’s degree Journal, The New York Times, Business and continued with graduate studies in Week, Time, and other publications. He is biology at Wayne State University. He a member of the editorial board of Health earned his medical degree at the University Affairs. He earned his doctorate in of Michigan School of Medicine. Sociology from the University of Chicago in 1973. Peter O. Kohler, M.D. President Michael M.E. Johns, M.D. Oregon Health Sciences University Executive Vice President for Health Affairs Emory University Dr. Kohler is president of Oregon Health Director Sciences University. After holding posi- The Robert W. Woodruff Health tions at the National Institutes of Health Sciences Center (NIH), he became professor of medicine Chairman of the Board and Chief and chief of the Endocrinology Division Executive Officer at Baylor College of Medicine. Later, he Emory Health Care served as chairman of the Department of Medicine at the University of Arkansas Dr. Johns heads Emory’s academic and and then as dean of the Medical School at clinical institutions and programs in the the University of Texas Health Science health sciences and is a professor in the Center in San Antonio. Dr. Kohler has Department of Surgery. A former dean of served on several boards. He has been the Johns Hopkins School of Medicine, he chairman of the NIH Endocrinology was professor and chair of the Study Section and chairman of the Board Department of Otolaryngology-Head and of Scientific Counselors for the National 42 Institute of Child Health and Human leadership positions at the Hospital of the Development. Dr. Kohler is a member of University of Pennsylvania in the Institute of Medicine and chaired the Philadelphia, UCLA Medical Center in recent task force on improving the quality Los Angeles, Los Angeles County – USC of long-term care. He is past-chair of the Medical Center, and Harbor – UCLA Board of Directors of the Association of Medical Center. Mr. Otten has taught at Academic Health Centers. Dr. Kohler California State University Los Angeles, received his bachelor of arts from the UCLA, Wharton, and the Harvard School University of Virginia and earned his of Public Health. He is director of corpo- medical degree at Duke Medical School. rate development of the Massachusetts Heart Association, chair-elect of the Board Edward D. Miller, Jr., M.D. of Trustees of the Greater Boston Food Dean and Chief Executive Officer Bank, a member of the Boston 2000 Johns Hopkins Medicine Consortium, and chair and executive The Johns Hopkins University committee member of University Healthsystems Consortium. Mr. Otten Dr. Miller is chief executive officer of also serves on the Board of the Council of Johns Hopkins Medicine. His former Teaching Hospitals at the Association of posts include chairman of the Department American Medical Colleges. He received a of Anesthesiology and Critical Care Master of Arts degree in 1975 and a Medicine; Interim dean of the School of Master of Business Administration degree Medicine; professor of anesthesiology and in 1983 from the University of California surgery and medical director of the at Los Angeles. Surgical Intensive Care Unit at the University of Virginia; E.M. Papper Mark L. Penkhus, M.H.A., M.B.A. Professor at Columbia University; and Executive Director and chairman of the Department of Chief Executive Officer Anesthesiology in the College of Vanderbilt University Hospital Physicians and Surgeons. Dr. Miller has authored and co-authored more than 150 Mr. Penkhus is chief executive officer and scientific abstracts and book chapters. He executive director of Vanderbilt University received his bachelor of arts from Ohio Hospital. Prior to joining Vanderbilt, Mr. Wesleyan University and his medical Penkhus was a partner and business unit degree from the University of Rochester leader for Healthcare Consulting (Mid- School of Medicine and Dentistry. Atlantic area) in Washington D.C. for Ernst and Young LLP and served as a , Jeffrey Otten, M.A., M.B.A. national leader for academic health cen- President ters. During his career, he has worked Brigham and Women’s Hospital with a variety of organizations as an inno- vator, and change agent with a special Mr. Otten is president of Brigham and emphasis on strategic, operational, and Women’s Hospital where he previously financial performance improvement. Mr. served as executive vice president and Penkhus received a bachelor of science chief operating officer. He has held senior degree from Iowa State University, a 43 master’s degree in Hospital and Health administration from Bowling Green State Care Administration from the University University and a bachelor of arts in of Iowa, and a masters of business admin- Accounting from Walsh College. He is a istration from Rensselaer Polytechnic member of AICPA, Ohio Society of CPAs, Institute in New York. He is also a gradu- Hospital Information Management ate of the Advanced Management Systems Society, and Healthcare Financial Program, Wharton School of Business, Management Association. at the University of Pennsylvania. He is a fellow of the American College of George F Sheldon, M.D. . Healthcare Executives (ACHE), a fellow Scholar in Residence in Project HOPE, Washington D.C., and a Burroughs Wellcome Fund member of the Johns Hopkins University School of Hygiene and Public Health, Dr. Sheldon’s background in graduate Department of Health Policy and medical education spans four institutions: Management. Mr. Penkhus serves on Kansas University, Mayo Clinic, several non-profit and for-profit boards University of California at San Francisco, in Tennessee and nationally. and Harvard University. He is currently scholar in residence at the Burroughs Paul L. Ruflin, M.B.A. Wellcome Fund. Previously he was chair- Vice President man and professor, Department of Surgery Health/Managed Care Consulting Practice at the University of North Carolina at Cap Gemini Ernst & Young U.S., LLC Chapel Hill and professor of surgery in the Department of Surgery at the Mr. Ruflin leads the health/managed care University of California, San Francisco. consulting practice for Cap Gemini Ernst He is a member of the Royal College of & Young U.S., LLC (CGE&Y) and is Surgeons of England and Scotland. Dr. responsible for all business development Sheldon has served as president of the and service delivery to CGE&Y’s provider, American Surgical Association, chairman managed care, and health/technology of the American Board of Surgery, member clients. He has more than twenty years of of the Council on Graduate Medical health care consulting experience with a Education, president of the American focus on developing and implementing College of Surgeons, chair of the Council strategies to transform health organiza- of Academic Societies of the Association tions including major providers and aca- of American Medical Colleges, and chair demic medical centers. He previously of the Association of American Medical served as director for business transfor- Colleges. He has published 195 articles mation services for the health consulting and book chapters and co-authored eight practice where he had national responsi- books. bilities for operations improvement, merg- er integration, turnaround, medical man- agement, physician practice management, supply chain, clinical improvement, and benefits realization services. Mr. Ruflin is a CPA, and holds a masters of business 44 Katherine W. Vestal, Ph.D. management and consulting in the areas Vice President of business transformation, post-merger Health Consulting Practice integration, and clinical management. Cap Gemini Ernst & Young U.S., LLC She speaks nationally on issues of organi- zational improvement and is a Malcolm Dr. Vestal leads the academic health cen- Baldrige National Quality Award ter sector for Cap Gemini Ernst & Young’s Examiner. Dr. Vestal received a bachelor (CGE&Y) health consulting practice of science in nursing from Texas Christian where she focuses on large-scale organiza- University, a master of science from Texas tional change for a wide range of health Women’s University, and a doctor of care delivery organizations. Prior to philosophy from Texas A & M University. joining CGE&Y, Dr. Vestal held several She is a Fellow of the Johnson and executive positions in academic health Johnson Wharton School of Finance, centers and taught at the graduate level at American College of Healthcare the University of Texas. Her background Executives, and the American Academy includes more than 25 years of operations of Nursing. 45 About the Invited Participants Haile T. Debas, M.D. Tipton Ford Dean, School of Medicine Senior Manager Vice Chancellor for Medical Affairs Cap Gemini Ernst & Young University of California, San Francisco Health Care Consulting Dr. Debas is dean of the School of Mr. Ford is a senior practitioner in Cap Medicine and serves as vice chancellor for Gemini Ernst & Young’s national academ- medical affairs at the University of ic medicine and physician services con- California, San Francisco. He previously sulting practice. He has over 19 years of served as chair of the Department of industry and consulting experience. Mr. Surgery at UCSF and he currently holds Ford consults exclusively with academic the Maurice Galante Distinguished health centers, independent teaching hos- Professorship of Surgery there. Dr. Debas pitals, and indigent care providers. His has served on the editorial boards of sev- major areas of consulting services include eral journals including Gastroenterology, academic department finance and opera- American Journal of Physiology, and tions, graduate medical education pro- American Journal of Surgery. He has served gram financing and operations, affiliation as a director of the American Board of agreement design, faculty physician prac- Surgery and a member of the governing tice operations, faculty compensation plan board of the American Gastroenterological design and implementation, large-scale Association; and as president of the operations and finance turn-around man- Society of Black Academic Surgeons, the agement, and research program financial International Hepato-Biliary-Pancreatic management. Mr. Ford is a member of the Association, and the Association for Medical Group Management Association, Academic Minority Physicians. He is a Academic Practice Assembly, Association member of the Institute of Medicine, of American Medical Centers, and National Academy of Sciences and a fel- Accreditation Council for Graduate low of the American Academy of Arts and Medical Education. He received a bache- Sciences. He serves on the executive lor of arts from Xavier University. board of the Association of American Medical Colleges and the membership Arthur Garson, Jr., M.D., M.P.H. committee of the Institute of Medicine. In Senior Vice President and Dean for 2001, he was elected president of the Academic Operations American Surgical Association. Dr. Debas Baylor College of Medicine received his medical degree from McGill University. Arthur Garson, Jr., is senior vice president and dean for Academic Operations at Baylor College of Medicine in Houston. He is also vice president of Texas Children’s Hospital with line responsibili- ty for quality, outcomes, and accreditation for the Integrated Delivery System includ- ing medical management, physician, and 46 clinic performance. Dr. Garson currently John Lynch chairs the National Heart, Lung, and Vice President, Global Human Resources Blood Institute Panel on Cardiovascular General Electric Medical Systems Research in the Young. He currently holds or previously held the following positions: John Lynch is the vice president, Global the Agency for Healthcare Research and Human Resources, for GE Medical Quality National Advisory Council; Systems, based in Milwaukee, Wisconsin. American College of Cardiology: presi- After graduating from University in dent, board of trustees, CME Scotland, Mr. Lynch worked in a series of Development Committee chairman; increasingly responsible HR roles for one American Medical Association: Relative of the U.K.’s major finance houses for 18 Value Update Committee (RUC) for years. He joined GE in 1991 as HR man- RBRVS; American Academy of Pediatrics: ager for the U.K. Auto Finance business Committee on Child Health Financing; of GE Capital. In 1994, he was promoted North American Society of Pacing and to HR leader for GE Capital Retailer Electrophysiology; board of trustees, edi- Finance – Europe and the following year tor for the U.S. and Canada of the journal moved to Stamford, Conneticut as senior Cardiology in the Young; Editorial Boards: HR leader for GE Capital Global Circulation, Journal of the American College Consumer Finance. John was appointed of Cardiology, American Journal of an officer of General Electric Company Cardiology, Pacing and Clinical and took up his current assignment with Electrophysiology, Journal of Cardiovascular Medical Systems in May 2001. Electrophysiology; Food and Drug Administration Cardiorenal Advisory Committee; NIH Small Business Innovative Research (SBIR) Study Section member; NIH Individual National Research Service Award Study Section member; Institute of Medicine Conflict of Interest Panel and Congressional Office of Technology Assessment Defensive Medicine Review Panel. He is the author of more than 450 publications including 7 books. Dr. Garson graduated from Princeton University in 1970 and received his medical degree from Duke University in 1974. 47 Appendix Baylor Metrics 2001 49 Baylor Metrics 2001 Clinical Departments Patient Care 1. Private Patient Care RVUs 3. Private Patient Care Expense Per RVU The RVU (Relative Value Unit) describes This is the expense per service. All how much time and effort a physician department expenses related to private spends performing a service: a routine patient care (e.g., physician salary and clinic visit is approximately 1 RVU where- fringe, staff, supplies, etc.) divided by as heart surgery receives 30 RVUs. This is RVU. Given the different incomes of a measure of how much activity all physi- physicians, the expense per RVU cannot cians perform; the higher the number of be meaningfully compared across depart- RVUs, the more outpatient visits and ments. However, the percent change from procedures are performed. one year to the next in the same depart- ment is a measure of change in resource 2. Private Patient Care RVUs Per Private utilization. Patient Care FTE 4. Patient Satisfaction – Patient- This is an efficiency measure, indicating Physician Relationship how efficiently physicians spend their time while seeing private patients. The An outpatient survey is administered by number of RVUs are divided by the num- telephone quarterly. Seven of the ques- ber of Full Time Equivalents (FTE) devot- tions relate to the physician (for example: ed to private patient care (excluding competency, caring, enough time spent Harris County and the VA hospital). Each with the patient). This number is the physician spends a certain percentage of overall patient assessment of the physi- their time seeing private patients – for cian. The maximum is 100. example, if he/she spends one day per week out of five, this is 20% or 0.2 FTE. 5. Patient Satisfaction – Process Of Care If the number of RVUs is divided by the patient care FTE, this normalizes the In the same survey, questions are asked patient care activity to what a 100% about “process,” such as: time to get an physician would spend. appointment, parking, courtesy of the staff, billing. This number is the overall The Medical Group Management assessment of the process. The maximum Association (MGMA) has benchmark data is 100. on private practice physicians throughout the U.S. We have chosen this measure as a benchmark for our physicians. For exam- ple, if the department of Otolaryngology is greater than 90th percentile for MGMA, this means that Baylor physicians see patients more efficiently than 90% of private otolaryngologists. 50 Research 6. Basic Science Laboratory Grant researcher would spend. This amount of Dollars Per Basic Science Laboratory funding (>$400,000 per Research FTE) Square Foot implies that, on average for the depart- ment, each research faculty member holds This is a measure of the efficiency of use more than one grant. of basic science or “bench” laboratory space. The grant dollars are those used to Education perform basic science – for the most part those investigations requiring animals, 8. Learner Evaluation genes, chemicals, microscopes, etc. The total grant dollars (direct dollars to the Periodically (whether after a single lecture, investigator plus the indirect dollars to or after a month with a physician or a year the institution) are used. The square feet with a mentor), learners (medical stu- used are those for investigators’ basic sci- dents, graduate students, residents, etc.) ence laboratories and other shared labora- are given the opportunity to evaluate their tory support space such as cold rooms. teachers. The evaluation form is similar Values more then approximately $350 per for each type of learning, and each asks square foot indicate crowded laboratories. the overall evaluation of the teacher on a scale of 1-7 with 7 being the highest. This 7. Grant And Contract Dollars Per metric is the average of every evaluation Research FTE received by faculty in the department. This is a measure of the productivity of Finance researchers. Both basic research (defined above in #6) and clinical research (gener- 9. Budget ally research on individual patients such as taking blood pressure, giving drugs, or Each year, each department submits a the support of such research, for example budget for the upcoming fiscal year. If, at by data collection or computer modeling) the end of the year, the actual revenue are included. The number of grant dollars minus expense (overall – all business seg- are divided by the number of Full Time ments) exceeded the prediction, the goal Equivalents (FTE) devoted to research. was exceeded. Each researcher spends a certain percent- age of their time doing research – for 10. Revenue Less Expense > 0 example, if he/she spends three days per week out of five, this is 60% or 0.6 FTE. If, at the end of the year, the overall rev- If the number of grant dollars is divided enue less expense was greater than zero by the research FTE, this normalizes the (regardless of the prediction), the goal research activity to what a 100% was exceeded. 51 Baylor Metrics 2001 Basic Science Departments Research 1. NIH Grant Dollars Per Tenure Track 3. Grant And Contract Dollars Per Faculty Research FTE For basic scientists, one important meas- This is a measure of the productivity of ure of the quality of research is whether researchers. Both basic research (defined the National Institutes of Health is fund- above in #6) and clinical research (gener- ing that grant. Since basic science depart- ally research on individual patients such ments are made up almost exclusively of as taking blood pressure, giving drugs, or individuals performing basic science, it is the support of such research, for example a goal for each tenure-track faculty mem- by data collection or computer modeling) ber to be funded by the National are included. The number of grant dollars Institutes of Health. While also true in the are divided by the number of Full Time clinical departments, there are prestigious Equivalents (FTE) devoted to research. funding sources for clinical research that Each researcher spends a certain percent- might come from other sources, and so age of their time doing research – for this is not a metric for clinical depart- example, if he/she spends three days per ments. This amount of funding week out of five, this is 60% or 0.6 FTE. (>$350,000 per faculty member) implies If the number of grant dollars is divided that, on average for the department, each by the research FTE, this normalizes the tenure track investigator holds more than research activity to what a 100% one NIH grant. researcher would spend. This amount of funding (>$400,000 per Research FTE) 2. Basic Science Laboratory Grant implies that, on average for the depart- Dollars Per Basic Science Laboratory ment, each research faculty member holds Square Foot more than one grant. This is a measure of the efficiency of use 4. Learner Evaluation: Graduate of basic science or “bench” laboratory Students and Medical Students space. The grant dollars are those used to perform basic science – for the most part Periodically (whether after a single lecture, those investigations requiring animals, or after a month with a physician or a year genes, chemicals, microscopes, etc. The with a mentor), learners (medical stu- total grant dollars (direct dollars to the dents, graduate students, residents, etc.) investigator plus the indirect dollars to are given the opportunity to evaluate their the institution) are used. The square feet teachers. The evaluation form is similar used are those for investigators’ basic sci- for each type of learning, and each asks ence laboratories and other shared labora- the overall evaluation of the teacher on a tory support space such as cold rooms. scale of 1-7 with 7 being the highest. This Values more then approximately $350 per metric is the average of every evaluation square foot indicate crowded laboratories. received by faculty in the department. 52 Graduate students rate teachers statistically lower than do medical students, hence the separate metrics. Finance 5. Budget Each year, each department submits a budget for the upcoming fiscal year. If, at the end of the year, the actual revenue minus expense (overall – all business seg- ments) exceeded the prediction, the goal was exceeded. 6. Revenue Less Expense > 0 If, at the end of the year, the overall rev- enue less expense was greater than zero (regardless of the prediction), the goal was exceeded. 53 References AAMC. 2001. Medical school applicant Blue Ridge Academic Health Group. pool continues to decline. AAMCSTAT. 1998b. Promoting Value and Expanded November 4. Online at www.aamc.org/ Coverage: Good Health is Good Business. newsroom/aamcstat/aamcnews.htm. 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Relman, A. S. 1994. The health care 2001. Current Findings on the Financial industry: where is it taking us? In The Status of Academic Health Centers. Nation’s Health (4th Edition), Lee, P R. . Presentation to the Commonwealth Fund and Estes, C. L. London: Jones and Task Force on Academic Health Centers Bartlett Publishers. Spring Meeting, April 27. Rice, D. P. 1994. Health status and national health priorities. In The Nation’s Health (4th Edition), Lee, P R. and Estes, . C. L. London: Jones and Bartlett Publishers. 56 Blue Ridge Academic Health Group Report Ordering Information If you would like to order more copies of this publication – or any of the others listed below – please contact Sharen Olson at Emory University: email solson@emory.edu or telephone at (404) 778-2968. When requesting publications, please refer to the report number and title and provide your full name, organization name, business address, city, state, zip, telephone, and email. Report 6 – Creating a Value-driven Culture and Organization in the Academic Health Center Report 5 – e-Health and the Academic Health Center in a Value-driven Health Care System Report 4 – In Pursuit of Greater Value: Stronger Leadership in and by Academic Health Centers Report 3 – Into the 21st Century: Academic Health Centers as Knowledge Leaders Report 2 – Promoting Value and Expanded Coverage: Good Health is Good Business Report 1 – Academic Health Centers: Getting Down to Business Retrieval File No. CGEY – AM076