14  Pursuing Excellence in Healthcare the university leaders felt that the health system and the university should sepa- rate. From an administrative standpoint, it was felt that an independent health system would be more nimble and thus better able to respond to the day-to-day challenges it faced in the competitive Philadelphia marketplace. However, when the leading candidate to succeed Dr. Kelly, Dr. Arthur Rubenstein, insisted on having control of the health system and the school of medicine, the university created “Penn Medicine.” Penn Medicine included the school of medicine, the health system, and the medical faculty practice plan under the leadership of the dean/executive vice president. [24] Rubenstein inherited a health system with a large amount of debt, with little money for growth and development, a location in a city with one of the lowest reimbursement rates in the country, four allopathic medical schools, and a harsh malpractice environment. Nonetheless, Penn has managed to remain a national leader in both clinical care and research. In 2008, the Hospital of the University of Pennsylvania ranked 12th in the U.S. News and World Report rankings and number 2 on the list of NIH-funded medical schools in 2005. Furthermore, development efforts have helped fund a group of major construction projects that will provide new and innovative facilities to help provide more seamless patient care, and investment in technology has allowed the hospital to compete effectively in the competitive environment of Philadelphia. Wake Forest University Recent evidence suggests that trustees of academic health centers are awakening to the necessity of higher levels of integration. A leading example is Wake Forest University Baptist Medical Center. An ad hoc working group of trustees of Wake Forest University Health Sciences and the North Carolina Baptist Hospital, the closed staff university hospital for the medical school and its faculty approved the reorganization of the components to a medical center model [27]. Both the medical school and the hospital were doing well individually; however, they had missed market opportunities, had difficulty deciding on capital investments, and wanted to invest more in the academic mission. e trustees committed to the reorganization to enable the enterprise to establish and execute an integrated clinical vision and strategy while maintaining the university’s autonomy and control over the academic mission. e Wake Forest model established an empowered medical center board populated by members of the health sciences board and the hospital board and added faculty members. ey established the position of medical center CEO, selected by and reporting to the medical center board and overseeing the work of presidents of university health sciences, the hospital, and a newly organized Integrating the Diverse Structures of Academic Medical Centers  15 faculty practice. Each executive has a dual reporting relationship to his or her respective boards for fiduciary responsibilities and to the CEO for executive leadership. Although it is too soon to comment on its success, it stands as a recent example of the kind of courageous and committed leadership necessary to achieve success in the contemporary AMC. Effect of the Staff Model on Structural Integration Another important structural component of an AMC is the form of its staff model. In the “closed” staff model, most of the physicians at the AMC— regardless of ownership—are full-time members of the academic faculty practice plan, and the hospital is empowered to restrict the number of physicians who can gain privileges at the hospital. By contrast, in the “open” staff model, some portion of the physician staff of the hospital are members of the full-time fac- ulty while other members of the medical staff are not employed by the medical school and are referred to as “voluntary” or “private” staff. e hospital is unable to control the influx of new physicians in the “open” staff model. Voluntary fac- ulty may have faculty appointments and patients are often unable to distinguish whether their physician is a member of the full-time faculty or of the voluntary faculty. Examples of “open” staff models are the omas Jefferson University Hospital and Hahnemann Hospital, whereas e Johns Hopkins Hospital and the Hospital of the University of Pennsylvania both use the closed staff model. In some cases, the relationship between the full-time faculty and the volun- tary or private faculty is symbiotic. Physicians who are not members of the full- time faculty may admit their patients to the academic hospital, teach residents and students, provide consultations within the hospital, and care for patients in their outpatient offices. In addition, they may refer their patients to the full-time faculty for highly specialized procedures such as cardiac catheterizations, trans- plantation, complex surgical procedures, or electrophysiology procedures. By contrast, voluntary faculty may compete with the full-time faculty for patients, may or may not teach the medical students or the residents, and pro- vide no monetary support for the academic missions of the medical school. In a less integrated center, they may live by their own set of rules and not be account- able for providing the same level of care as the full-time faculty—thereby pro- viding a natural substrate for “town–gown” conflicts, especially when resources are limited. As we will see in later chapters, at some AMCs, voluntary faculty may not be accountable to department chairmen or their political clout may supersede a chair’s authority, thereby obviating the ability of the chair to regulate their performance and to ensure quality of care. However, voluntary faculty may have strong political clout when the hospital is not integrated with the university 16  Pursuing Excellence in Healthcare and may see integration as a threat to their autonomy—a possibility that must be factored into attempts at integration. Recommendations for Integrating AMC Structure As you can see from the preceding pages, our research has shown that the most effective means of attaining the core mission of providing outstanding patient care can be achieved by integrating the components of the AMC: the hospital, the medical school, the physician practice plan, and the university. Only with integration can contemporary AMCs fund and accomplish their tripartite mis- sions and, in competitive markets, succeed as a distinctive clinical enterprise. e academic health centers with the highest levels of performance and the best reputations were founded as, or are evolving toward, highly integrated enter- prises. Even some university-based academic health centers that separated their hospitals in the 1990s to protect the university’s endowment are now moving back toward an integrated governance and leadership model. However, this new model requires more than just integration for success: It requires that all elements have an integrated core focus of providing outstanding patient care because success in the clinical mission is an absolute requirement for success in the academic mission. Restructuring is fraught with challenges in today’s AMC. For example, there is no perfect structure for any single AMC and structure alone cannot solve all problems. Great thought must be given to the creation of a new gov- ernance structure to ensure that the reorganization is successful. Organization models must be carefully analyzed in terms of benefits and limitations. Inherent internal politics at all AMCS often impede reorganization; therefore, external support services with experience in restructuring AMCs may be required. In terms of leadership, it is a rare executive who is willing to engage in a process that may lead to the change or diminution of his or her role. us, restructur- ing may and often does require leadership change. As a result, the initial impe- tus for change has most often come from the board of trustees rather than from individual executives. Nonetheless, there must be both courage and commitment at the level of the board in approaching this sphere of action. Restructuring is not easy and positive effects might not be immediately obvious. In addition, because of complex political factors, it is often useful to have the process driven by external healthcare consultants who have the experience and expertise and a diverse array of methods for effectively bringing about change in complex structures. e following recommendations can serve as a template for achiev- ing integration. Integrating the Diverse Structures of Academic Medical Centers  17 Drive Integration from the Top Restructuring efforts must come from the top; that is, senior leadership must initiate changes and base them on the clear and well-defined goal of improv- ing patient care. is type of initiative must involve the board of trustees of both the hospital and the university. e boards must commit to and be actively involved in the integration of their AMCs. Indeed, in many cases it may be the board of trustees that actually initiates and drives the process of integration. In these cases, the board should utilize external experts in healthcare management to assist in developing a strategic plan for integration in order to avoid internal politics. Include All Stakeholders in the Process of Integration All stakeholders must be involved in the process, including faculty, hospital administrators, university administrators, and department chairs. Where appro- priate, community representatives and state legislatures should be involved in the process. In programs that have significant numbers of voluntary faculty, they too should be included in the process of integration. Depending on the process and the situation, faculty, students, and staff may be involved in the strategic planning process. However, even when the reintegration is driven from the level of the board, there must be a sharing of the vision and an assurance that all stakeholders understand the goals and objectives of integration and have a shared vision. To achieve the goals of integration, flexibility will be required at all participant levels. Develop a Framework for Integration That Can Withstand Changes over Time It may be helpful for the AMC to utilize some of the “change” models that have been developed within the context of industry. ese include methodologies that allow institutions to create a shared need, shape a vision, mobilize com- mitment, make change last, and monitor progress in order to make change last. Programs that support change include “Six Sigma” (define, measure, improve, and control), “Lean,” and the “Change Acceleration Process” (CAP). AMCs that do not have leaders familiar with mechanisms of change may bring in any one of a number of consulting groups to help the organization develop a strategic plan based on a defined algorithm. 18  Pursuing Excellence in Healthcare Ensure That the Central Focus of Integration Is Improved Patient Care e ultimate goal of integration is to support the core mission of achieving excellence in patient care. In many respects, it is axiomatic that an integrated AMC can provide the highest level of patient care by aligning the incentives and management across the hospital, the physician group, and the medical school. However, as is true with each of these spheres, integration is necessary but not sufficient to reach the core goal. Interestingly, integration influences each of the four different spheres because alignment of the hospital and university also leads to greater opportunities in and resources for research and education. References 1. Billings, J. 1875. Hospital construction and organization. Hospital plans. New York: William Wood & Co. 2. Ludmerer, K. 1999. Time to heal: American medical education from the turn of the century to the era of managed care, 514. New York: Oxford University Press. 3. Dowling, H. 1982. City hospitals: e undercare of the underprivileged. Cambridge, MA: Harvard University Press. 4. Petersdorf, R. G. 1980. e evolution of departments of medicine. New England Journal of Medicine 303 (9): 489–496. 5. Stevens, R. 1986. Issues for American internal medicine through the last century. Annals of Internal Medicine 105 (4): 592–602. 6. Kirch, D. 2006. Financial and organizational turmoil in the academic health cen- ter: Is it a crisis or an opportunity for medical education? Academic Psychiatry 30 (1): 5–8. 7. Gee, D. A., and Rosenfeld, L. A. 1984. e effect on academic health centers of tertiary care in community hospitals. Journal of Medical Education 59:547–552. 8. Stanford Hospital and Clinic Medical Staff UPDATE. 2000. 24 (11). 9. Kane, N. 2001. e financial health of academic medical centers: An elusive sub- ject. In e future of academic medical centers, ed. H. Aaron, 101. Washington, D.C.: Brookings Institute Press. 10. Karash, J. A. 1996. KU job cutback denied. e Kansas City Star, Feb. 6 (www. firecehelathcare.com/node/8296/print). 11. King, S. 2008. KU Hospital’s independent path has led to success. e Kansas City Star, Oct. 7 (www.kansascity.com/105/story/312331.html). 12. Maguire, P. 1998. Allegheny’s failure sends shocks through academia. ACP-ASIM Observer, Dec. (www.acponline.org/journals/news/dec98/failure.htm) 13. Aaron, H. 2000. Brookings Policy Brief 69. e plight of academic medical centers. 14. Levine, J. K. 2002. Considering alternative organizational models for academic medical centers. Academic Clinical Practice 14 (2): 2–5. Integrating the Diverse Structures of Academic Medical Centers  19 15. Wartman, S. 2007. e academic health center: Evolving organizational models. Washington, D.C.: Association of Academic Health Centers. 16. Heyssel, R. 1984. e challenge of governance: e relationship of the teaching hospital to the university. Journal of Medical Education 59:162–168. 17. Allison, R. F., and Dalston, J. W. 1982. Governance of university-owned teaching hospitals. Inquiry 19 (1): 3–17. 18. Weisbord, M. 1975. A mixed model for medical centers: Changing structure and behavior. In New technologies in organization development, ed. J. Adams, 211–254. La Jolla, CA: University Associates. 19. Hastings, D. A., and Crispell, K. R. 1980. Policy-making and governance in aca- demic health centers. Journal of Medical Education 55 (4): 325–332. 20. Petersdorf, R. 1987. Some thoughts on medical center governance. Pharos Fall:13–18. 21. Culbertson, R. A., Goode, L. D., and Dickler, R. M. 1996. Organizational models of medical school relationships to the clinical enterprise. Academic Medicine 71 (11): 1258–1274. 22. Keroack, M. A., Youngberg, B. J., Cerese, J. L., Krsek, C., Prellwitz, L. W., and Trevelyan, E. W. 2007. Organizational factors associated with high performance in quality and safety in academic medical centers. Academic Medicine 82 (12): 1178–1186. 23. Collins, J. 2001. Good to great. New York: Harper Collins. 24. Kastor, J. 2003. Governance of teaching hospitals: Turmoil at the University of Pennsylvania and the Johns Hopkins University. American Journal of Medicine 114 (9): 774–776. 25. Kastor, J. 2001. Mergers of teaching hospitals: ree case studies. American Journal of Medicine 110 (1): 76–79. 26. Warren, M. 2000. Johns Hopkins, knowledge for the world. Baltimore, MD: the Johns Hopkins University. 27. http://www.wfubmc.edu/ceo 21 2Chapter Integrating Clinical Care Delivery Systems A teaching hospital will not be controlled by the faculty in term-time only; it will not be a hospital in which any physician may attend his own case. Centralized administration of wards, dispensary, and laboratories, as organically one, requires that the school relationship be continuous and unhampered. e patient’s welfare is ever the first consideration: we shall see that it is promoted, not prejudiced, by the right kind of teaching. Abraham Flexner, 1910 [1] Introduction It would be easy to blame the problems of today’s AMCs on the unwieldy structural relationships that exist among the hospital, the medical school, and the university that were described in Chapter 1; however, the structure of the medical school itself often precludes the ability of AMC physicians to pro- vide outstanding patient care. e modern American medical school consists of numerous clinical departments that often operate in their own individual silos. is nonintegrated structure presents a number of different challenges to achieving the core mission of providing outstanding patient care. For example, at some AMCs, the same procedure may be provided in multiple departments 22  Pursuing Excellence in Healthcare without the development of common protocols and without an assessment of which group of physicians does it best. Another example of how a lack of integration across different departments adversely influences patient care is the geographic separation of closely related specialists. As a result, patients must travel from one outpatient location to another and go through a registration process at each location; their care is often interrupted as the patient has to wait for the different physicians to communi- cate with each other regarding his or her care. In this chapter, we will look at the historic structure of the medical school, the evolution of the physician practice plan, types and examples of integration, and recommendations for integrating care across departmental boundaries. Medical School Structure—A Historical Perspective When Osler, Halsted, Welch, and Kelly established the departmental structure of e Johns Hopkins School of Medicine in 1893, the medical school consisted of only four clinical departments: medicine, surgery, pathology, and obstetrics and gynecology. Abraham Flexner described the model at Hopkins when he recommended [1]: ere will be one head to each department—a chief, with such aides as the size of the service, the degrees of differentiation feasible, the number of students, suggest. e professor of medicine in the school is physician-in-chief to the hospital; the professor of surgery is surgeon-in-chief; the professor of pathology is hospital pathologist. School and hospital are thus interlocked. In the hospital, all clinical care was overseen by the chairman of the depart- ment of medicine or the chairman of the department of surgery. e number of physicians in each department was very small and the department chiefs often saw each of the patients on their particular service. Indeed, Osler warned of the potential consequences of the early rise of specialists and their separation from their parent departments when he noted [2]: e student-specialist may have a wide vision—no student— wider—if he gets away from the mechanical side of the art and keeps in touch with the physiology and pathology upon where his art depends. More than any other of us, he needs the lessons of the labo- ratory, and wide contact with men in other departments may serve Integrating Clinical Care Delivery Systems  23 to correct the inevitable tendency to a narrow and perverted vision, in which the life of the ant-hill is mistaken for the world at large. us, even at the turn of the century, Osler cautioned against thinking in silos rather than integrating care. roughout the twentieth century, the departmental structure of the medi- cal school changed as an increasing number of individual departments were formed. In the early part of the century, new departments formed, including pediatrics and psychology. ese were followed later in the century by depart- ments of neurology, rehabilitation medicine, radiology, and anesthesiology. After World War II, individual fields of specialization arose in the disci- plines of medicine and surgery. In departments of medicine, subspecialty divi- sions formed in cardiology, gastroenterology, infectious diseases, pulmonary medicine, critical care medicine, rheumatology, endocrinology, medical genet- ics, clinical pharmacology, hematology, oncology, and emergency medicine. Most of these subspecialties remained embedded in the departments of medi- cine, although departments of emergency medicine and oncology became sepa- rate departments in many institutions. In departments of surgery, subspecialty divisions arose in critical care medicine; cardiothoracic surgery; plastic surgery; transplant surgery; urology; ear, nose, and throat surgery (otorhinolaryngology); and neurosurgery. By contrast with departments of medicine, most of the surgical subspecialties became separate departments. As a result, many medical schools have over 20 dif- ferent clinical departments. By the 1960s and 1970s, some departments, includ- ing medicine and surgery, became larger than entire medical schools had been a decade earlier; however, the administrative structure of medical schools did not change to accommodate these marked differences. As a result, departments often became independent fiefdoms that further entrenched the silo model— often battling each other for the limited resources that exist in today’s AMCs. Historic Departmental Structure Can Impede Delivery of Outstanding Patient Care is traditional departmental structure impedes the delivery of outstanding and seamless patient care. In addition, it limits the ability of individual departments to develop shared accountability for quality of care and to collaborate in the care of a patient, as well as impedes the ability to ensure that quality rather than politics is the deciding factor as to who provides specific services. [...]... enhance the clinical and translational research enterprises of all participants For example, the amalgamation of a cardiology program having a rich basic science program with a cardiothoracic surgery program, a vascular program, and a radiology program having a paucity of basic science research provides a unique opportunity for the programs to link at the translational research level just as they are... hospital organizations have little control over the individual practices, and the practices are not integrated with the hospital, thereby obviating the ability of the hospital and the physicians to share costs Clinical integration should be something that can be effected in the context of group practice plans in an academic health center Unfortunately, the cultural, financial, and governance issues that exist... cases, financially and administratively separate from their affiliated university (M D Anderson Cancer Center, Memorial Sloan-Kettering Cancer Center, The Kimmel Cancer Center of Johns Hopkins Hospital, Dana-Farber Cancer Institute, and the Fred Hutchinson Cancer Center of the University of Washington) Thus, it would appear that, based on the cancer center experience, clinical and financial integration... dean or provost can cause equal problems when appointments and promotions, finances, and recruitment are maintained in the traditional department When individual faculty members receive support of any kind from both the service line director and the department chair, the creation of a service line functionally adds another silo to the AMC Faculty members, staff, and students can play the chair and the. .. interdisciplinary programs aimed at curing human disease [14] Patients want to feel that their care is well organized and that they are interacting with physicians who bring the most up -to- date knowledge and Integrating Clinical Care Delivery Systems    31 treatment approaches to their care [15] A service line approach could also give AMCs a competitive edge against for-profit clinical carve-outs that organize... that are federally designated and funded by the National Cancer Institute of the National Institutes of Health By contrast with the traditional academic departments, these centers are often multidisciplinary, cross many departmental barriers, and have a broad agenda that includes basic and clinical research, excellence in patient care, training and education, development of new technologies, and cancer... that delegates to the center director the authority and responsibility for the activities of all members of the center and dedicated resources, including clinical and research space, and reports to the CEO of Emory Healthcare, the dean of the School of Medicine, and the director of the Emory Clinic The traditional stakeholders in transplantation medicine, including department chairs, are included as... Mary Lasker, Sidney Farber, Laurence Rockefeller, Benno Schmidt, and Ann Landers, and a panel of consultants as well as the senatorial leadership of Senator Ralph Yarborough [6] In order to develop the financial and organizational structure for the new cancer centers, this group of concerned citizens studied the leading cancer programs of the time—all of which were free-standing institutions, including... Roswell Park, Memorial Sloan-Kettering, and M D Anderson Based on these studies, the federal legislation mandated that the cancer center director control all funds, including those associated with philanthropy, indirect costs, and clinical revenues and that the individual have a level of “institutional authority” appropriate to manage the center [7] As a result, AMCs had a choice: Develop a cancer center... that exist in the traditional AMC limit the development of clinical integration, so only a handful of academic centers have made substantive inroads in developing seamless patient care Early Efforts in Developing Service Lines Modeled after product lines in many industries, service lines began to gain popularity in the 1980s as a means of improving patient care, providing cost-effective care across multiple . has managed to remain a national leader in both clinical care and research. In 20 08, the Hospital of the University of Pennsylvania ranked 12th in the U.S. News and World Report rankings and. from the level of the board, there must be a sharing of the vision and an assurance that all stakeholders understand the goals and objectives of integration and have a shared vision. To achieve. of providing outstanding patient care. If an AMC uses the core mission of providing outstanding patient care to adjudicate internal conflicts, the choice that an administrator must make regarding