While the need to address disparities in care is well known, few strategies for reducing disparities have been studied systematically.
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.
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:
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.
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.
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.
Study of the Organizational Structures of Academic Health Centers
Association of Academic Health Centers, Inc. (Washington, DC)
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.)
Bulger R, Osterweis M, Rubin ER, eds. Mission Management: A New Synthesis, Volume 1. Washington, D.C.: Association of Academic Health Centers, June 1999.
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
Section 2: Refining the Mission of the Academic Health Center
Section 3: Lessons from Corporate American and the International Scene
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:
"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:
"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:
"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:
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.
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.
Report prepared by: Lori De Milto
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Lewis Sandy (SPO)
Program Officer: Beth A. Stevens
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