Mission Of Academic Medical Centers Research Articles

The Stanford Medicine data science ecosystem for clinical and translational research.

To describe the infrastructure, tools, and services developed at Stanford Medicine to maintain its data science ecosystem and research patient data repository for clinical and translational research. The data science ecosystem, dubbed the Stanford Data Science Resources (SDSR), includes infrastructure and tools to create, search, retrieve, and analyze patient data, as well as services for data deidentification, linkage, and processing to extract high-value information from healthcare IT systems. Data are made available via self-service and concierge access, on HIPAA compliant secure computing infrastructure supported by in-depth user training. The Stanford Medicine Research Data Repository (STARR) functions as the SDSR data integration point, and includes electronic medical records, clinical images, text, bedside monitoring data and HL7 messages. SDSR tools include tools for electronic phenotyping, cohort building, and a search engine for patient timelines. The SDSR supports patient data collection, reproducible research, and teaching using healthcare data, and facilitates industry collaborations and large-scale observational studies. Research patient data repositories and their underlying data science infrastructure are essential to realizing a learning health system and advancing the mission of academic medical centers. Challenges to maintaining the SDSR include ensuring sufficient financial support while providing researchers and clinicians with maximal access to data and digital infrastructure, balancing tool development with user training, and supporting the diverse needs of users. Our experience maintaining the SDSR offers a case study for academic medical centers developing data science and research informatics infrastructure.

The Academic Learning Health System: A Framework for Integrating the Multiple Missions of Academic Medical Centers.

The learning health system (LHS) has emerged over the past 15 years as a concept for improving health care delivery. Core aspects of the LHS concept include: promoting improved patient care through organizational learning, innovation, and continuous quality improvement; identifying, critically assessing, and translating knowledge and evidence into improved practices; building new knowledge and evidence around how to improve health care and health outcomes; analyzing clinical data to support learning, knowledge generation, and improved patient care; and engaging clinicians, patients, and other stakeholders in processes of learning, knowledge generation, and translation. However, the literature has paid less attention to how these LHS aspects may integrate with the multiple missions of academic medical centers (AMCs). The authors define an academic learning health system (aLHS) as an LHS built around a robust academic community and central academic mission, and they propose 6 features that emphasize how an aLHS differs from an LHS. An aLHS capitalizes on embedded academic expertise in health system sciences; engages the full spectrum of translational investigation from mechanistic basic sciences to population health; builds pipelines of experts in LHS sciences and clinicians with fluency in practicing in an LHS; applies core LHS principles to the development of curricula and clinical rotations for medical students, housestaff, and other learners; disseminates knowledge more broadly to advance the evidence for clinical practice and health systems science methods; and addresses social determinants of health, creating community partnerships to mitigate disparities and improve health equity. As AMCs evolve, the authors expect that additional differentiating features and ways to operationalize the aLHS will be identified and hope this article stimulates further discussion around the intersection of the LHS concept and AMCs.

Evolution of the Chief Medical Officer Role in Teaching Hospitals and Health Systems.

Clinical physician leaders have become an increasingly important asset to hospitals and hospital systems in a changing healthcare environment. Specifically, the role of the chief medical officer (CMO) has expanded and evolved amid the shift to value-based payment models and sharpened focus on patient safety, quality, community engagement, and equity in healthcare, as well as a global pandemic. In light of these changes, this study examined the transformation of CMOs and similar roles and evaluated the current needs, challenges, and responsibilities of clinical leaders today. The primary data source used in this analysis was a survey fielded to 391 clinical leaders in 290 Association of American Medical Colleges-member hospitals and health systems in 2020. In addition, this study compared responses to the 2020 survey with findings from two prior iterations of the survey from 2005 and 2016. The surveys collected information regarding demographics, compensation, administrative titles, qualifications for the position, and the scope of the role, among other questions. All surveys consisted of multiple-choice, free response, and rating questions. The analysis was conducted using frequency counts and percentage distributions. Thirty percent of eligible clinical leaders responded to the 2020 survey. Twenty-six percent of the clinical leader respondents identified as female. Ninety-one percent of the CMOs were members of the senior management team in their hospital or health system. CMOs reported that they were responsible for five hospitals, on average, with 67% indicating they were responsible for more than 500 physicians. This analysis provides hospital and health systems with insight into the expanding scope and complexity of CMOs as they take on greater leadership responsibilities within their institutions amidst a shifting healthcare landscape. In reflecting on our results, hospital leaders can understand the current needs, barriers, and responsibilities of today's clinical leaders.

An Investigation of Organizational Correlates of Distress in Non-Clinician Biomedical Researchers in the United States.

Challenges ushered by the COVID-19 pandemic led to an increased focus on the mental well-being of the healthcare workforce. Despite the important contribution non-clinician biomedical researchers make to the mission of academic medical centers, the well-being of this unique population remains understudied in the United States. The purpose of this study was to examine the individual and organizational correlates of distress among non-clinician biomedical researchers. A survey was delivered to employees of a large academic medical center in the southeastern United States, including non-clinician biomedical researchers. Participants were asked to assess their own well-being using the validated Well-Being Index (WBI) tool, resilience, work and nonwork-related stressors and demographic descriptors. Descriptive statistics and bivariate analyses were conducted, and binary logistic regression was used to examine predictors of increased odds of overall distress. Nearly 44% of surveyed non-clinician biomedical researchers met the threshold for high distress which indicates an increased risk of suicidal ideation, turnover intention, and burnout. The major correlates of distress were at the organizational level, including perceived organizational support (OR 0.79, 95% CI 0.70-0.90), heavy workload and long hours (OR 3.25, 95% CI 1.53-6.88), inability or lack of support to take time off (OR 2.80, 95% CI 1.03-7.66) and conflict with supervisor (OR 5.03, 95% CI 1.13-22.1). While lower individual resilience (OR 0.69, 95% CI 0.54-0.88) was statistically significantly associated with greater distress, it accounted for less than 10% of the overall variance when controlling for other work-related factors. These findings suggest that developing organizational interventions that address institutional support for non-clinician biomedical researchers within academic medical centers represents an important opportunity to reduce distress within this population. While emphasizing individual resiliency as an important in the pursuit of well-being, it is also the responsibility of the organization to create and foster an environment in which employees can access their own resilience.

Implementation and Utilization of a Web-Based Departmental Annual Faculty Review Program.

Supporting faculty in their professional development is a central mission of academic medical centers (AMCs), assisted by routine assessment of faculty development. However, AMCs face barriers to standard faculty assessment, particularly among large departments with diverse faculty roles. We report on the development, implementation, and utilization of a standardized, web-based faculty annual career review (FACR) process deployed within the Department of Medicine at a large AMC, composed of 22 divisions and 1400 faculty. The FACR process was developed to achieve the following goals: Creation of a trackable review of professional goals and barriers to professional development; provide longitudinal faculty reflection on professional growth; and provide data to identify faculty development needs to target initiatives. The FACR was initiated in 2008. We provide specific case examples of utilization of the FACR data for targeted faculty development initiatives, including (1) division benchmarking; (2) targeting career opportunities to individual faculty members; and (3) longitudinal data analysis of 5-year trends of FACR response, including subanalysis by gender, to target faculty development initiatives across the DOM. In summary, we demonstrate successful development, implementation, and utilization of a web-based standard faculty annual review program within a large AMC that allows for systematic evaluation and reflection of professional development by faculty members and their supervisors and allows for data collection and analysis to help target faculty development initiatives.

Evaluation of the Stanford Anesthesiology Faculty Teaching Scholars Program Using the Context, Input, Process, and Product Framework.

Faculty development programs are essential to the educational mission of academic medical centers as they promote skill development and career advancement and should be regularly evaluated to determine opportunities for improvement. The context, input, process, and product (CIPP) framework evaluates all phases of a program and focuses on improvement and outcomes. The aim of this study was to use the CIPP framework to evaluate the Stanford Anesthesiology Faculty Teaching Scholars Program. Using the CIPP framework, a survey was developed for alumni (2007 to 2018) of the program, followed by structured interviews, and each interview was deductively coded to identify themes. Twenty-six of the 54 (48% response rate) participants in the program completed the survey, with 23 completing their projects and 17 of those projects still part of the anesthesiology training program. Seventeen survey responders went on to educational leadership roles. Twenty-five of the 26 survey responders would recommend this program to their colleagues. Fifteen structured interviews were conducted. Using the CIPP framework, themes were identified for context (reason for participation, previous experience in medical education, and resident education impact), input (benefits/negatives of the lecture series, availability of resources, and adequacy of nonclinical time), process (resident participation, mentorship, and barriers to implementation), and product (project completion, education sustainability, positive/negative outcomes of the program, and suggestions for improvement). The CIPP framework was successfully used to evaluate the Teaching Scholars Program. Areas of improvement were identified, including changing the program for input (add education lectures customized to faculty interests) and process (formally designate an experienced mentor to faculty).

Redesign of US Medical Schools: A Shift from Health Service to Population Health Management.

The integration of medical schools and clinical partners is effectively established through the formation of academic medical centers (AMCs). The tripartite mission of AMCs emphasizes the importance of providing critical clinical services, medical innovation through research, and the education of future health care leaders. Although AMCs represent only 5% of all hospitals, they contribute substantially to serving disadvantaged populations of patients, including an estimated 37% of all charity care and 26% of all Medicaid hospitalizations. Currently, most AMCs use a business model centered upon revenue generated from hospital services and/or practice plans. In the last decade, mounting financial demands have placed significant pressure on AMC finances because of the rising costs associated with complex clinical care and operating diverse graduate medical education programs. A shift toward population health-centric health care management strategies will profoundly influence the predominant forms of health care delivery in the United States in the foreseeable future. Health systems are increasingly pursuing new strategies to manage financial risk, such as forming Accountable Care Organizations and provider-sponsored plans to provide value-based care. Refocusing research and operational capacity toward population health management fosters collaboration and enables reintegration with hospital and clinical partners across care networks, and can potentially create new revenue streams for AMCs. Despite the benefits of population health integration, current literature lacks a blueprint to guide AMCs in the transformation toward sustainable population health management models. The purpose of this paper is to propose a modern conceptual framework that can be operationalized by AMCs in order to achieve a sustainable future.

Reader Response 1a: Challenges to Successful Research Careers in Neurology: How Gender Differences May Play a Role.

We read the interesting report by Minen et al.1 on sex disparities in the neurology research pipeline. The authors highlighted unique factors contributing to high rates of attrition among women faculty—besides family obligations—and discussed the negative implications of their early departure on the educational mission of academic medical centers. In addition to destabilizing the foundation of academic integrity, the sex gap in senior leadership roles in neurology threatens future opportunities for advancement of women. The disproportionately low numbers of women professors and chairs in neurology departments, of presidents of professional societies, of senior editors of specialty journals, and of recipients of AAN recognition awards are several examples of sex-related gaps.2,3 As Minen et al. suggest, NIH has attempted to promote career development for women through the Responsible Conduct of Research model, but the environment in research has not been entirely conducive to the 3 pillars. Because gaps have not closed on their own, intentional and strategic efforts at multiple levels are pivotal to meet the career goals of many talented and qualified women in neurology.4 The time is now to commit much needed additional resources to overcome structural and institutional barriers for women physicians and scientists in academic neurology.

Marketing the Research Missions of Academic Medical Centers: Why Messages Blurring Lines Between Clinical Care and Research Are Bad for both Business and Ethics.

Academic Medical Centers (AMCs) offer patient care and perform research. Increasingly, AMCs advertise to the public in order to garner income that can support these dual missions. In what follows, we raise concerns about the ways that advertising blurs important distinctions between them. Such blurring is detrimental to AMC efforts to fulfill critically important ethical responsibilities pertaining both to science communication and clinical research, because marketing campaigns can employ hype that weakens research integrity and contributes to therapeutic misconception and misestimation, undermining the informed consent process that is essential to the ethical conduct of research. We offer ethical analysis of common advertising practices that justify these concerns. We also suggest the need for a deliberative body convened by the Association of American Medical Colleges and others to develop a set of voluntary guidelines that AMCs can use to avoid in the future, the problems found in many current AMC advertising practices.

Do Academic Health Care Systems Really Value Education? A Survey of Academic Plastic Surgeons.

Background:Although education is critical to the mission of academic medical centers in the United States, it is often not quantified and monetized as are their research and clinical missions. We undertook this survey to assess the perceived valuation of educational endeavors of plastic surgeon faculty at the U.S. academic medical centers.Methods:A survey using Qualtrics software (Qualtrics, Provo, UT) was distributed to faculty members of the American Council of Academic Plastic Surgeons by electronic mail in February 2015. A total of 16 questions included both demographic information and Likert-item questions of perception of valuation of educational activities. For analysis, responses were grouped according to an adapted Net Promoter Score including “unsupportive” (0–6), “neutral” (7–8), and “supportive” (9–10).Results:Sixty-five surveys were completed out of a total of 406, with an overall response rate of 16%. Kruskal-Wallis statistical analysis demonstrated that region and rank were not significant in perception of hospital or departmental support for educational activities. Respondents rated their departments as more supportive than their institutions (P < 0.05), and average perceived value rating of institutions was “unsupportive.” Financial support was associated with higher ratings with respect to support of institutions and departments. Mid-career faculty displayed a trend toward lower ratings of perception of support.Conclusions:The majority of respondents perceived their institutions and departments as unsupportive of educational effort. Direct compensation to physicians for teaching efforts may improve faculty retention in academia and reduce physician burnout.

Assessing the effort associated with teaching residents

Intraoperative resident education is an integral mission of academic medical centers and serves as the basis for training the next generation of surgeons. The actual effort associated with teaching residents is unknown as it pertains to additional operative time. Using a large validated multi-institutional dataset, this study aims to quantify the effect of having a resident present in common plastic surgery procedures on operative time. Future directions for developing standardized methods to record and report teaching time are proposed, which can help inform prospective studies. The 2006-2012 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database was queried to identify seven isolated plastic surgical procedures that were categorized based on resident involvement and supervision. Linear regression models were used to calculate the difference in operative time with respect to resident participation while controlling for patient and operative factors. Resident involvement was associated with longer operative times for muscle flap trunk procedures (53min, 95% CI=[25, 80], p-value=0.0002) and breast reconstruction procedures with a latissimus dorsi flap (55min, 95% CI=[22, 88], p-value=0.001). For six of the seven surgeries evaluated, resident involvement was associated with longer operative times, as compared to no resident involvement. Resident involvement is associated with an increase in operative time for certain plastic surgery procedures. This finding underscores the need for a mechanism to quantify the time and effort that the attending surgeons allocate toward intraoperative resident education. Further study is also necessary to determine the causal impact on patient care.

Teaching speed in the operative theatre: Should case duration benchmark efficiency in general surgical residency programs?

BackgroundTraining surgical residents remains an important mission of academic medical centers. Today, financial pressures guide improved operating room (OR) efficiency and theoretically may affect surgical education. There is no current benchmark with regards to operative time and surgical cases involving General Surgical Residents. Study design971 laparoscopic surgical cases were reviewed for total operative time, closing time, length of stay and 30-day readmission rates. T-test of means and regression analyses were done involving surgical times and point in time during the academic year of the surgical program to gauge whether efficiency improvements exist in the program. Regressions were also done comparing surgical times (total operative and closing time to outcome measures: length of stay, 30-day readmission, and log cost). ResultsResidents had significantly longer procedure times compared to the year prior to commencement of the program where attending surgeons operated without residents by mean t-test (p<0.05). Length of stay increased as total operative time increased in 4 of the 6 category cohort of cases that general surgical residents were involved (p<0.05). There was no improvement in closing time among residents throughout the academic year of their program nor when comparing successive program years.There were strong and statistically significant correlations between total operative time and cost. ConclusionResident participation contributes to increased procedure time and cost for common laparoscopic general surgical procedures. There is also a link between outcomes as measured by length of stay and total operative time. Consequently teaching and/or maintaining efficiency standards may be paramount to maintaining better outcomes. General surgical residency programs may consider benchmarking operative and/or closing times in guiding efficiency in their programs.

Procedural Portfolio Planning in Plastic Surgery, Part 2: Collaboration Between Surgeons and Hospital Administrators to Develop a Funds Flow Model for Procedures Performed at an Academic Medical Center.

Although plastic surgeons make important contributions to the clinical, educational, and research missions of academic medical centers (AMCs), determining the financial value of a plastic surgery service can be difficult, due to complex cost accounting systems. We analyzed the financial impact of plastic surgery on an AMC, by examining the contribution margins and operating income of surgical procedures. We collaborated with hospital administrators to implement 3 types of strategic changes: (1) growth of areas with high contribution margin, (2) curtailment of high-risk procedures with negative contribution margin, (3) improved efficiency of mission-critical services with high resource consumption. Outcome measures included: facility charges, hospital collections, contribution margin, operating margin, and operating room times. We also studied the top 50 Current Procedural Terminology codes (total case number × charge/case), ranking procedures for profitability, as determined by operating margin. During the 2-year study period, we had no turnover in faculty; did not pursue any formal marketing; did not change our surgical fees, billing system, or payer mix; and maintained our commitment to indigent care. After rebalancing our case mix, through procedural portfolio planning, average hospital operating income/procedure increased from $-79 to $+816. Volume and diversity of cases increased, with no change in payer mix. Although charges/case decreased, both contribution margin and operating margin increased, due to improved throughput and decreased operating room times. The 5 most profitable procedures for the hospital were hernia repair, mandibular osteotomy, hand skin graft, free fibula flap, and head and neck flap, whereas the 5 least profitable were latissimus breast reconstruction, craniosynostosis repair, free-flap breast reconstruction, trunk skin graft, and cutaneous free flap. Total operating income for the hospital, from plastic surgery procedures, increased from $-115,103 to $+1,277,040, of which $350,000 (25%) was returned to the practice plan as enterprise funds to support program development. Through focused strategic initiatives, plastic surgeons and hospital administrators can work together to unlock the latent value of a plastic surgery service to an AMC. Specific financial benefits to the hospital include increased contribution margin and operating income, the latter of which can be reinvested in the plastic surgery service through a gain-sharing model.

Mediterranean Symposium in Thoracic Surgery: Opening Lectures

Giacomo p ignataro, rector of the u niversity of Catania It is with great pleasure that I accepted to introduce this important symposium on lung metastasectomy. There are several reasons that I would like to address in this short introduction. In the era of global financial crisis in all Europe, including the universities, our response is to guarantee that the investments done are widely used to empower our next generation of researchers and, above all, to implement the benefits of patients in the healthcare system. Furthermore, the link between universities and medical companies will be of a paramount importance, in order to organize important meetings like this one, that could serve as a flywheel to invest in research projects. Academia in medicine is the balance between excellence in clinical service, education and research. If the mission of academic medical centers remains confused with the activities in support of the mission, academic medicine is in danger of perpetuating an inefficient system and ultimately a confusing set of goals.

Succeeding as a Clinician Educator: Useful Tips and Resources

Clinician Educators (CEs) play an essential role in the education and patient care missions of academic medical centers. Despite their crucial role, academic advancement is slower for CEs than for other faculty. Increased clinical productivity demands and financial stressors at academic medical centers add to the existing challenges faced by CEs. This perspective seeks to provide a framework for junior CEs to consider with the goal of maximizing their chance of academic success. We discuss six action areas that we consider central to flourishing at academic medical centers: 1. Clarify what success means and define goals; 2. Seek mentorship and be a responsible mentee; 3. Develop a niche and engage in relevant professional development; 4. Network; 5. Transform educational activities into scholarship; and 6. Seek funding and other resources.

How we develop and sustain innovation in medical education technology: Keys to success

The use of information technology to support the educational mission of academic medical centers is nearly universal; however, the scope and methods employed vary greatly (Souza et al. ). This article reviews the methods, processes, and specific techniques needed to conceive, develop, implement, and assess technology-based educational programs across healthcare disciplines. We discuss the core concepts, structure, and techniques that enable growth, productivity, and sustainability within an academic setting. Herein are specific keys to success with examples including project selection, theory-based design, the technology development process, implementation, and evaluation that can lead to broad participation and positive learning outcomes. Most importantly, this article shares methods to involve students, faculty, and stakeholders in technology design and the development process that fosters a sustainable culture of educational innovation.

Thoughts on Teaching (for Orthopaedic Graduates) *

The house of academic medicine is supported by four pillars, which include clinical care, administration, research, and teaching. These pillars sustain the diverse missions of academic medical centers. Our subspecialty of orthopaedic surgery is also supported by these pillars. Clinical care is the largest and strongest pillar of academic medicine and orthopaedics. All value in health care begins with service to patients, and providing high-quality, safe health care is critical to the success of all medical centers and all orthopaedic practices. Administration is a necessary pillar. Competent, knowledgeable, and diligent administrators are very important for medical centers and orthopaedic practices, as they manage the complex processes associated with the clinical and academic missions. Research is an essential pillar of academic medicine and orthopaedic surgery. Besides providing new knowledge, new services, new products, and innovations that improve the care we offer to our patients, research can generate additional revenue for medical centers. During my career, research in orthopaedics has led to subspecialization in orthopaedic surgery, which, in general, has improved patient care. Specific clinical advances that I have observed include arthroscopic surgery, microsurgery for neurovascular reconstruction, cartilage restoration, cementless hip replacement, instruments and navigation for total knee arthroplasty, advances in spine surgery, and techniques and products for orthopaedic trauma care. These innovations have succeeded because they relieve pain and improve function for orthopaedic patients. Orthopaedic research improves the lives of our patients, and research is an essential pillar in the house of orthopaedics. Teaching is the fourth pillar of academic medicine and orthopaedics, although teaching can be an undervalued and overlooked pillar. Teaching generates less revenue than clinical care and research, generates administrative costs, and takes time to do well. Despite the critically important fact that teaching programs train the next generation of physicians and orthopaedic surgeons, the importance of the …

Payment Reform and the Mission of Academic Medical Centers

U.S. academic medical centers (AMCs) are facing new challenges to their financial well-being. As payers seek to control health care costs, teaching hospitals and their medical staffs can anticipate continued payment reductions. Under the fee-for-service system, hospitals respond to payment cuts by increasing their volumes of admissions and ambulatory services while improving efficiency. Although costs per case may decline, overall costs do not. The inevitable result is a further reduction in per-case payments, and the cycle continues — with many undesirable consequences. Costs are inflated, and the quality and safety of care are eroded as the result of unnecessary or . . .

Commentary: What If High-Quality Care Drove Medical Education? A Multiattribute Approach

The current medical education model is based on the assumption that students progress from a mastery of basic mechanisms of human structure and function to an understanding of a variety of pathologies and treatments using sound scientific principles. In this commentary, the authors suggest another approach to developing medical school curricula. Starting with the major desired outcome of medical education, which they suggest should be high-quality medical care, educators can work backward using the attributes of quality as the basis for developing new medical curricula. The authors present, as an example, the Institute of Medicine definition of quality care--care that is safe, timely, effective, efficient, equitable, and patient-centered. These objectives and their attributes then can be useful for mapping current and future curricula in medical education and identifying deficits or possible excesses. A result of this approach might be the inclusion of such topics as epidemiology, process engineering, or aspects of the humanities or social sciences that build skills and knowledge in patient-centered care or safety while maintaining a balance with the need to preserve biomedical topics. Use of quality objectives and attributes to drive medical education should lead to improved alignment of the clinical and educational missions of academic medical centers, which, in turn, should lead to safer and higher quality care for patients.

Authors' Reply: Faculty Values

Authors' Reply: Dialogue on values and professionalism in academic medicine is always welcome, and we thank Drs. Poses and Smith, as well as JGIM for this opportunity. The purpose of our hypothesis-generating research study and the article1 was to document deeply held values of faculty in the context of understanding the culture of academic medicine2. We reported that many faculty are distressed in perceiving that behaviors they witness, and that are rewarded in academic medicine organizations, are not always congruent with their own values. In response to Drs. Poses’ and Smith’s letter, we definitely did not mean to suggest that faculty should become congruent with their leaders when they (leaders) are out of alignment with the mission of academic medical centers to provide excellence in patient care, education, and research, as well as access to all — including underserved vulnerable populations. The questionable behaviors that some faculty described betray the public trust and the lofty intentions of the great academic medical institutions in this country as expressed in their mission statements. In fact, we checked the mission statements of the index medical schools and were reassured by the similarity of faculty values and the mission statements.