Organizational Restructuring Can Help Academic Health Centers Adapt to Industry Changes
From 1996 to 1998, the Association of Academic Health Centers (AHC) characterized organizational models that might enable academic health centers (ahcs) to survive and prosper in a changing environment and to assess the impact of the changing clinical environment on education and research missions.
The study was based on the hypothesis that certain characteristics define how institutions function and that some structures permit more change than others.
Located in Washington, the Association of Academic Health Centers is a national, non-profit organization that seeks to improve health and well-being through leadership of the nation's academic health centers.
- To manage each mission area (education, research, patient care and community service), academic health centers must develop business plans with objectives, accountabilities and outcomes.
- Ownership, governance, leadership, organization and financing for each mission area must be addressed.
- Leadership and management are both required for success and must be anchored in clearly stated values.
- Successful academic health centers of the future must be oriented toward institutional goals and objectives and not based solely on individual disciplines, schools or professions.
- Academic health centers must develop and make known performance metrics and benchmarks in all mission areas.
The Robert Wood Johnson Foundation (RWJF) supported this project through a grant of $200,000.
Academic health centers (ahcs) are a primary national resource for health professional education, biomedical and health services research, and patient care. Each ahc consists of a school of medicine, one or more other health professional schools or programs, and one or more teaching hospitals. They may be university-based or freestanding health sciences universities; many ahcs are part of state university systems.
Recent scientific, economic, and social forces have produced one of the most challenging periods in AHC history. Advances in genetics, molecular biology, and information sciences are dramatically expanding the horizons of health care and will require significant investments to be incorporated into health care delivery systems.
At the same time, ahcs are facing enormous pressures from managed care; the static level and uncertainty of research funding; new societal demands and expectations related to cost, efficiency, and accountability; and criticism from commentators on academic medicine that they have grown apart from many of society's needs. In addition, two-thirds of the nation's 124 ahcs are public institutions and face decreasing or static state funding.
All these forces are compelling ahcs to adapt quickly and creatively to preserve their ability to serve their core missions of education, research, and patient care. A variety of organizational and structural characteristics, most notably adherence to the department-chair model, have been frequently identified as inhibiting creative change, but few experts have recommended sweeping organizational changes. In the past, major foundations have tried to alter the curricula of medical and other health professional schools with only minor success.
The Association of Academic Health Centers (AHC), a national, nonprofit organization representing more than 100 of the nation's ahcs, hypothesized that the organizational changes being forced on the service components of ahcs because of the dramatic alterations in the health care delivery system would have a domino effect on the organizational characteristics of the research and educational enterprises, including relationships among the health professional schools and their parent universities.
AHC also hypothesized that a typology of organizational structures for ahcs and a clearly articulated set of benchmarking characteristics would allow not only for monitoring of changes in organization but would also assist institutions in becoming more proactive about their futures.
Four months before the AHC received this RWJF grant, it began preliminary work on a smaller study examining these hypotheses, funded by the University HealthSystem Consortium, an organization of teaching hospitals and academic health systems located in Oakbrook, Ill., dedicated to enhancing the position of their members in the marketplace. The RWJF grant enabled the AHC to expand the study.
This grant provided funds to the AHC to characterize ahcs according to their organizational structures and articulate models that might enhance their ability to survive and prosper. Conducted from November 1996 to October 1997, the study had four goals.
Goal #1: To understand the influence of environmental forces and recognize their impact on the ahcs' tripartite mission education, research, and service. To accomplish this goal, the grantee:
- Commissioned a set of 17 background papers (7 with Foundation support) by experts in the field. Papers span a wide range of issues from higher education to international health, address the specific mission areas and/or leadership issues of ahcs, and highlight promising approaches and solutions to challenges facing ahcs.
- Surveyed AHC member institutions to get a global sense of changes at ahcs in their structures, governance, financing, and organization; the survey had a 74 percent response rate.
- Hired the Kaludis Consulting Group to conduct site visits to the University of Cincinnati Medical Center, University of Colorado Health Sciences Center, University of Massachusetts Medical Center, and Baylor College of Medicine, to better understand how managed care and its requirements for lower costs and greater efficiency and accountability are playing out in these ahcs' clinical environments and affecting their academic missions of education and research, leadership roles, and relationships with their parent universities and communities.
- Developed 11 mini case studies, highlighting strategies that individual AHC members have used to affect change. See Appendix 1 for the list of ahcs on which case studies were conducted.
Goal #2: To articulate a vision for academic health center success in the 21st century through a contemporary re-statement of mission and values. The grantee appointed a study advisory committee (see Appendix 2), comprised of AHC and University HealthSystem Consortium leaders, university presidents, and university hospital and health system CEOs, to guide the project, oversee the report, and develop its conclusions, including the vision statement. This project also received grants from the University HealthSystem Consortium ($100,000) and The Commonwealth Fund ($25,000).
Goal #3: To identify a range of models and strategies characteristic of successful ahcs, including the relationships among their components, with their parent universities, and with their communities. The grantee attempted to develop some typologies of ahcs, including basic structure and more detailed classification of organizational arrangements for different mission areas. They determined that the fluidity and high variability across institutions would make any typology either so global that it would miss key aspects or so detailed that few institutions would fit into any category. Nonetheless, they learned that almost half of AHC members function on their own campus either with their own board or within a statewide system; a few institutions recently separated the health sciences administratively from the rest of the university; the great majority of the remainder are part of a comprehensive university; in several institutions, the medical school dean is also the CEO of the health system; academic integration across professions occurs within several medical schools that have degree-granting programs in public health, allied health professions, and some nursing programs.
AHC synthesized lessons learned from the study into "best practices" for ahcs to use as benchmarks for their own progress, laying out various models and describing institutional examples of them. Analysis of the results of the survey of responding AHC members was still under way at the time this report was written.
Goal #4: To inform institutional and national policy decisions on organizational and economic structures for health professions education, biomedical and health service research, and health care delivery. The activities under this goal are described in the section on Communication.
OBSERVATIONS AND CONCLUSIONS
- Governmental and market forces are increasing the emphasis on institutional and faculty member accountability to an unprecedented level.
- Most ahcs are taking steps to alter their programs and structures.
- No single model is right for all ahcs. Institutional history, culture, and mission, as well as characteristics of parent universities or university systems will shape the strategies ahcs choose.
- Change involves deep cultural shifts; it alters the roles of leaders at all levels and has a tremendous impact on faculty and their traditions.
- Faculty roles and responsibilities are changing, particularly for departmental chairs. An increased emphasis on new tenure arrangements, faculty performance and productivity assessments, and post-tenure reviews was noted.
- Strategy and focus are increasingly important factors for the success of ahcs. Some ahcs are moving toward "mission management" to achieve their goals and away from the traditional department- or discipline-based approach.
- Financing and societal realities push ahcs toward separating the management of the service, research, and educational enterprises, yet other forces call for their re-integration across the academic enterprise.
- A fourth mission area, highlighted by the study, is community service.
- To manage each mission area (education, research, patient care, and community service), ahcs must develop business plans with objectives, accountabilities, and outcomes.
- Ownership, governance, leadership, organization, and financing for each mission area must be addressed.
- Leadership and management are both required for success and must be anchored in clearly stated values. A shared vision of change among top leaders provides the greatest likelihood of engineering creative change; this vision must be clearly communicated.
- Successful ahcs of the future must be oriented toward institutional goals and objectives and not based solely on individual disciplines, schools, or professions. They must link institutional priorities to allocation and reward systems.
- Ahcs must develop and make known performance metrics and benchmarks in all mission areas.
- Executives must be risk-takers and must be allowed to make occasional mistakes. They must earn trust by appropriate communication with stakeholders.
- Investment in information systems must be dramatically increased in most ahcs.
- Clinical restructuring provides an opportunity to consider organizational restructuring to align faculty to work in functional units while remaining within academic departments.
The study's fourth goal, to inform decision-making, was accomplished through publishing and disseminating the findings. AHC released the Executive Summary of its study, Mission Management: A New Synthesis, at the Howard Hughes Medical Institute research conference in February 1998. It received major coverage in the trade press, including The Blue Sheet, a weekly newsletter on health policy and biomedical research published by F-C-Reports, Inc. The two-volume study, Mission Management: A New Synthesis, has been written.
Volume 1 contains the observations, conclusions and recommendations, the reports on the site visits, the survey results, 11 case studies, and a paper on the development of the new role of the clinical chair one of the most significant elements of change and synthesis.
Volume 2 consists of the commissioned background papers. 2,000 copies of each volume were distributed through the major nonprofit health professions educators' associations and major teaching hospital organizations. The Executive Summary has been put on the AHC's Web site.
AHC also published individual reports of the case studies. Study results were disseminated through presentations at the AHC's annual and spring meetings in 1997 and 1998. AHC held seminars and forums for members, health professional educators' groups, and university presidents. Other seminars were held with the University Healthsystem Consortium. See the Bibliography for complete information.
AFTER THE GRANT
The AHC continued the analysis of the survey of their members, and it will continue to monitor the activities of its members and to discuss and analyze various organizational issues in association seminars and meetings. A Council for the University and Health Sciences, comprised of university presidents and CEOs of academic health centers, was established to discuss the impact of the study's findings on university presidents.
To highlight the importance of the community service mission, the AHC has established the American Network of Health Promoting Universities and plans to submit a proposal to RWJF for an annual award to be given to one academic center that has made a difference in the health of the community.
The AHC will continue to monitor and analyze best practices for each mission area and will share this information through occasional papers and issue briefs as appropriate. This work informed a similar Foundation grant to the Association of American Medical Colleges (grant ID# 028234) to establish a leadership group to consider the challenges that changes in the health care system create for academic medicine.
GRANT DETAILS & CONTACT INFORMATION
Study of the Organizational Structures of Academic Health Centers
Association of Academic Health Centers, Inc. (Washington, DC)
Dates: November 1996 to March 1998
Roger J. Bulger, M.D.
AHCs Receiving Case Studied
Cornell University Medical College
The University of Illinois at Chicago
The Medical College of Wisconsin
The Oregon Health Sciences University
The Pennsylvania State University and The Geisinger Health System
Rush-Presbyterian-St. Luke's Medial Center
The University of Texas Southwestern Medical Center at Dallas
Tulane University and Columbia/HCA
Wake Forest University / Bowman Gray School of Medicine
College of Osteopathic Medicine of the Pacific as it joined with the College of Allied Health Professions and the College of Pharmacy to become Western University of Health Sciences
Study Committee on the Organization of Academic Health Centers
Roger L. Bulger, M.D., Chair
Association of Academic Health Centers
Robert J. Baker
University HealthSystem Consortium
Oak Brook, Ill.
Dennis C. Brimhall
University of Colorado
Gerard N. Burrow, M.D.
New Haven, Conn.
Mary Sue Coleman, Ph.D.
The University of Iowa
Iowa City, Iowa
Michael J. Halseth
University of Virginia Health Sciences Center
Donald C. Harrison, M.D.
University of Cincinnati Medical Center
Leo M. Henikoff, M.D.
Rush-Presbyterian-St. Luke's Medical Center
Thomas H. Jackson, J.D.
University of Rochester
Peter O. Kohler, M.D.
Oregon Health Sciences University
Aaron Lazare, M.D.
University of Massachusetts
Russell Miller, M.D.
State University of New York Health Science Center at Brooklyn
Ralph W. Muller
The University of Chicago Hospitals and Health Systems
Froedtert Memorial Lutheran Hospital, Inc.
Graham B. Spanier, Ph.D.
Pennsylvania State University
University Park, Pa.
Ralph Snyderman, M.D.
Duke University Medical Center
Kaludis Consulting Group
Association of Academic Health Centers Staff, Washington, D.C.
Marian Osterweis, Ph.D.
Elaine Rubin, Ph.D.
(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)
Books and Reports
Bulger R, Osterweis M, Rubin ER, eds. Mission Management: A New Synthesis, Volume 1. Washington, D.C.: Association of Academic Health Centers, June 1999.
- "Minding the Tripartite Mission," Elaine R. Rubin, Ph.D.
- "The Evolving Structure, Organization, and Governance of Academic Health Centers," Marian Osterweis, Ph.D.
- "Site Visit Report," Kaludis Consulting Group.
- "Development of the New Role of the Clinical Chair," Julien F. Biebuyck, M.B., D.Phil.
- Cornell University Medical College: The End of an Era of Cross-Subsidization of Research.
- Creighton University: Changing Partners to Ensure the Future.
- The University of Illinois at Chicago: Strategies and Structures for Managing the Academic Health Center.
- The Oregon Health Sciences University: Becoming a Public Corporation.
- The Pennsylvania State University and The Geisinger health System: The Anatomy of a Merger.
- Rush-Presbyterian-St. Luke's Medical Center: Transforming a Freestanding Academic Health Center.
- The University of Texas Southwestern Medical Center at Dallas: The End of an Era of Cross-Subsidization of Research.
- Tulane University and Columbia/HCA: Selling a University Hospital for a For-Profit System.
- Wake Forest University/Bowman Gray School of Medicine: Exploring the Future Organization of Academic Health Centers.
- Western University of Health Sciences: Creating a New Educational Environment.
- The Medical College of Wisconsin: Repositioning a Private, Freestanding Academic Health Center for the 21st Century.
19971998 AHC Survey Questionnaire
Rubin ER, ed. Mission Management: A New Synthesis, Volume 2. Washington, D.C.: Association of Academic Health Centers, 1998.
Section I: A New University for a New Millennium
- "Universities in the 21st Century," Robert H. Atwell.
- "Technology's Transformation of the University," Eli Noam, Ph.D.
- "Leadership, Culture, and Change: Critical Elements for Transformation," Carol A. Aschenbrener, M.D.
- "Leadership Amid Change: The Challenge to Academic Health Centers," Gregory L. Eastwood, M.D.
- "Confronting the Realities of Creating an Institutional Culture," Jane E. Henney, M.D.
Section 2: Refining the Mission of the Academic Health Center
- "The Changing Nature of Health Professions Education," John Naughton, M.D.
- "Weaving a Tapestry of Change: Quality and Values in Education," Paul B. Batalden M.D.; John P. Evans, Ph.D.; Jeanne C. Ryer, M.S.
- "The Case for Interdisciplinary Education," DeWitt C. Baldwin, Jr., M.D.
- "Mentors, Advisors, and Role Models in Graduate and Professional Education," Judith P. Swazey, Ph.D.; and Melissa S. Anderson, Ph.D.
- "Making Sense of the Tenure Debate," Elaine R. Rubin, Ph.D.
- "Assessing Resource Requirements and Financing for Health Professions Education," Meredith A. Gonyea, Ph.D.
- "The Research Mission of Academic Health Centers," David Blumenthal, M.D., M.P.P.
- "Restructuring the Research Enterprise for the Future," Ralph Snyderman, M.D.
- "Research Administration for the 21st Century: The UCSF Research Administration Project," Karl J. Hittelman, Ph.D.; and Mary Beth O'Connor, M.B.A.
- "The Clinical Enterprise: Creating New Strategies and Structures," Robert J. Baker.
- "Health Care Delivery: A Marketplace in Evolution," Alan L. Hillman, M.D., M.B.A.
Section 3: Lessons from Corporate American and the International Scene
- "The Changing Shape of American Companies: Implications for Academic Health Centers," Charles C. Snow, Ph.D.
- "The Globalization of Health Care," John Wyn Owen, C.B.
Association of Academic Health Centers. Mission Management: A New Synthesis. Executive Summary. Washington, D.C.: Association of Academic Health Centers, 1998.
Bennett S, Chase P, Kuehn CS, Leo J, Rosenberg H, Trinca CE, Younoszai R, and Rubin ER. Transition to a University: Opportunities to Create a New Educational Environment. Washington, D.C.: Association of Academic Health Centers, 1996.
Bolger TM and Rubin ER. The Medical College of Wisconsin: Repositioning a Private Freestanding Academic Health Center for the 21st Century. Washington, D.C.: Association of Academic Health Centers, 1996.
Davis L, Kohler P, and Rubin ER. The Oregon Health Sciences University Becomes a Public Corporation. Washington, D.C.: Association of Academic Health Centers, 1996.
Evarts CM. The Anatomy of a Merger: The Penn State Geisinger Health System. Washington, D.C.: Association of Academic Health Centers, 1996.
LaRosa J and Rubin ER. Tulane University and Columbia/HCA. Washington, D.C.: Association of Academic Health Centers, 1996.
Rubin ER and Haussmann RKD. The University of Illinois at Chicago: Strategies and Structures for Managing the Academic Health Center. Washington, D.C.: Association of Academic Health Centers, 1996.
Rubin ER and Henikoff LM. Rush-Presbyterian-St. Luke's Medical Center: Transforming a Freestanding Academic Health Center. Washington, D.C.: Association of Academic Health Centers, 1996.
Rubin ER and Janeway R. Exploring the Future of Academic Health Centers: Wake Forest University Bowman Gray School of Medicine. Washington, D.C.: Association of Academic Health Centers, 1996.
Rubin ER and O'Brien R. Creighton University: Changing Partners to Ensure the Future. Washington, D.C.: Association of Academic Health Centers, 1996.
The End of an Era of Cross Subsidization of Research: A Case Study of Cornell University Medical College. Washington, D.C.: Association of Academic Health Centers, 1996.
The End of an Era of Cross Subsidization of Research: A Case Study of the University of Texas Southwestern Medical Center at Dallas. Washington, D.C.: Association of Academic Health Centers, 1996.
"Creating the Future," Association of Academic Health Centers Annual Meeting, September 2326, 1998, Tucson, Ariz. Attended by 100 people including university presidents and trustees, academic health center CEOs, and AHC staff. Ten presentations:
- Denise D. Kornegay and David Rearick, "Innovative Financing of Ambulatory Education."
- Jay Noren, "The Value of Academic Health Centers: Survey Results of Community Opinion Leaders."
- Michael Macoby, "On Creating the Organization for the Age of Learning."
- F. Stephen Larned, "Complexity Science and Leadership of Academic Health Centers."
- Paul C. Brucker, "Health Systems and Education: Responsibilities and Benefits."
- Arthur Garson, Jr., "Metrics: Using Report Cards for Faculty and Academic Departments."
- Barbara F. Atkinson, "Mission, Management and Resource Allocation."
- Delores G. Clement and Hermes Kontos, "Doctoral Education at a Distance: Interdisciplinary Program in Health Related Sciences."
- Regina E. Herzlinger, "Market-Driven Health Care."
- David A. Burnett, Michael A. Geheb, and Donald C. Harrison, "Funds Flow and Clinical Enterprise Management."
"How Far Beyond the Gates?" Association of Academic Health Centers Spring Meeting, March 2324, 1998, Washington, D.C. Attended by 100 people including AHC members and staff, foundation heads, and members of the Federation of Association of Schools of the Health Professions Council. Eight presentations:
- Richard Riley, "Opening the Gates The Three Rs: Rationale, Responsibilities, and Realities."
- Ann Swindler, "The University: Redefining an American Institution."
- Uwe E. Reinhardt, "Positioning Academic Health Centers for the Future."
- Kay Dickersin, "Community and Patient Input: New Approaches to Research Design."
- Sarena Seifer, "Community-Campus Partnerships for Health: National Study on Academic Health Centers."
- C. Peter Magrath, "New Frontiers in Education."
- W. Benton Boone, "Striking a Balance with the Community."
- Donald F. Hagen, "Universities and Economic Development: A Tale of Two Cities."
"Association of Academic Health Centers Forum on University Relations: Review and Discussion of Preliminary Conclusions and Recommendations from the AHC's Organization Study," November 19, 1997, Washington, D.C. Attended by 15 university presidents and CEOs of ahcs.
"Discovering the Future: The Organization of Academic Health Centers," Association of Academic Health Centers Annual Meeting, September 2427, 1997, Indian Wells, Calif. Attended by 111 people from ahcs and their parent universities. Eleven presentations:
- George Klaudis and Roger Bulger, "Study Report: Observations, Conclusions, and Recommendations."
- David J. Ramsay and David R. Smith, "Organizational Models: Implications for Leadership."
- Aaron Lazare, Jane E. Henney, and Paul E. Stanton, Jr., "Confronting the Realities of Institutional Culture."
- DeWitt C. Baldwin, Jr., "The Case for Interdisciplinary Education."
- Karl Hittelman, "Managing the Research Enterprise."
- R.K. Dieter Haussmann and M. David Low, "Translating Business Practices into the University Culture."
- Alan L. Hillman, "Merger Mania: A Case Study."
- John Wyn Owen, "The Globalization of Health Care."
- Robert Baker, "The Clinical Service Environment: Lessons for the Future."
- Charles Snow, "The Changing Shape of American Companies."
- Anthony L. Barbato, Eugene A. Bauer, Frank B. Cerra, David R. Challoner, Gregory L. Eastwood, C. McCollister Evarts, and Michael A. Geheb, "Innovation in the Era of Health Systems."
"Association of Academic Health Centers: Forum on University Relations," April 8, 1997, Washington, D.C. Attended by 21 university presidents and heads of ahcs from 18 institutions. Discussion centered around academic health center organizational models.
"Expanding the Dialogue on Governance and Leadership," Association of Academic Health Centers Spring Meeting. March 2425, 1997, Washington, D.C. Attended by 97 people including university presidents and trustees, academic health center CEOs, and representatives of health and education-related associations. Four presentations:
- Stanley Ikenberry, "Crisis or Continuity for the University in the 21st Century."
- Lenox D. Baker, Jr., Marshall Field, Shirley M. McFee, and N. Theodore Sommer, "Confronting the Challenges of University Trusteeship."
- Thomas H. Jackson, Graham B. Spanier, H. Patrick Sywgert, and Charles T. Wethington, "Presidential Perspectives on Managing Universities."
- Joseph Steger, Francis J. Tedesco, Susan Dentzer, Robert Hemenway, and James W. Holsinger, Jr., "Restructuring Higher Education? How Does the Academic Health Center Fit?"
Presentations and Testimony
Bulger R. "Mission Management: A New Synthesis. Executive Summary," at the Howard Hughes Medical Institute Research Conference, Chevy Chase, Md., February 1998.
Bulger R. "The Name of the Game is Mercy: Foundational Values and Multiprofessional Education." University of Iowa's "Redefining Education in Primary Care: Teaming Communities, Practitioners, and Educators," Conference, Iowa City, Iowa, April 1617, 1997.
Bulger R. "Humanism and the 21st Century Academic Health Center" and "The 21st Century University: Opportunities to Create a New Educational Environment," at the Western University of Health Sciences, Pomona, Calif., February 45, 1997.
World Wide Web Sites
Web site at www.aahcdc.org provides information on ahcs. Washington, D.C.: Association of Academic Health Centers. May 1998; average 2,500 viewers per month.
"ahcs Need to Develop Business Plan for Research, AHC Concludes: All ahcs Should Conduct Studies." The Blue Sheet, March 4, 1998.
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