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
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the university leaders felt that the health system and the university should 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]
sepa-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 The 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
The 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 They 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
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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 The hospital is unable
to control the influx of new physicians in the “open” staff model Voluntary 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 Thomas Jefferson University Hospital and Hahnemann Hospital, whereas The Johns Hopkins Hospital and the Hospital of the University of Pennsylvania both use the closed staff model
fac-In some cases, the relationship between the full-time faculty and the 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
volun-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
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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 The 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 Thus, 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 The following recommendations can serve as a template for achiev-ing integration
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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 This type of initiative must involve the board of trustees of both the hospital and the university The 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 These 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
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Ensure That the Central Focus of Integration
Is Improved Patient Care
The 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: The undercare of the underprivileged Cambridge,
MA: Harvard University Press
4 Petersdorf, R G 1980 The 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 The 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 The financial health of academic medical centers: An elusive
sub-ject In The future of academic medical centers, ed H Aaron, 101 Washington,
D.C.: Brookings Institute Press
10 Karash, J A 1996 KU job cutback denied The Kansas City Star, Feb 6 (www.
14 Levine, J K 2002 Considering alternative organizational models for academic
medical centers Academic Clinical Practice 14 (2): 2–5.
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15 Wartman, S 2007 The academic health center: Evolving organizational models
Washington, D.C.: Association of Academic Health Centers
16 Heyssel, R 1984 The challenge of governance: The 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
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
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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 The 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 The modern American medical school consists
of numerous clinical departments that often operate in their own individual silos This 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
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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 The 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]:
There 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 The 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 ment of medicine or the chairman of the department of surgery The 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]:
depart-The 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
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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
Thus, even at the turn of the century, Osler cautioned against thinking in silos rather than integrating care
Throughout the twentieth century, the departmental structure of the 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 These 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
medi-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
This 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
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The inefficiency of the current departmental structure is highlighted by the ongoing controversies between cardiologists and radiologists at many AMCs about who will image the heart and the peripheral vasculature Radiologists and cardiologists perform a variety of invasive and noninvasive procedures to image the heart Radiologists argue that these lie in their domain because they believe that they hold the exclusive franchise on “imaging” within an AMC However, cardiologists also provide the same services in the private practice community and in some AMCs and believe that they have rights to the franchise by virtue
of the fact that they are the ones who care for the patients and who must pret the tests in order to make clinical decisions Because they perform the same procedures, the “turf” battles between radiologists and cardiologists become an important case study for understanding how the silos of academic medical cen-ters influence decision making and the “business” of medicine and can impede the core mission of providing outstanding patient care
inter-If an AMC uses the core mission of providing outstanding patient care
to adjudicate internal conflicts, the choice that an administrator must make regarding who should perform cardiovascular imaging becomes quite simple The development of an integrated program makes the most sense Radiologists can bring their expertise in imaging while cardiologists can provide their exper-tise in the anatomy of the heart and the various disease processes, resulting in a
“product” that is far superior to what either group could offer alone
Unfortunately, at a time when it is well recognized that collaborative and multidisciplinary approaches provide the best care for patients, the American College of Radiology has not concurred that collaboration in cardiac imaging
is appropriate [3] Furthermore, the leaders of many AMCs have allowed itics—rather than the core mission of providing outstanding patient care—to guide their decision-making processes, resulting in one of the two silos captur-ing the franchise for cardiovascular imaging without a mandate for collabora-tion and compromise
pol-Evolution of the practice plan
Historically, individual clinical departments of medical schools were sible for doing their own billing and collections from patients or insurance com-panies Sometimes these billing operations existed within the medical school and at other times they were carried out by outside organizations When the financial operations were outside the university or medical school, they were led
respon-by the department chairman and overseen respon-by an independent board Although the department was expected to provide a “tax” to the dean and to the univer-sity to support the academic missions of the schools, at many medical schools
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the individual department chairs had authority over the use of the remaining resources; this gave them a large amount of authority and power
Today, almost all medical schools have unified the billing operations of their individual departments under a single practice plan, largely to facilitate compli-ance with federal regulations and billing guidelines The majority of these practice plans are subsidiaries of the parent university, although some are owned by the hospital and a smaller number remain independent For example, at Georgetown, the practice plan was sold, along with the university hospital, to a health sys-tem that included the Washington Hospital Center; at the New Jersey Medical School, the practice plan is separate from both the university and the hospital.Regardless of “ownership,” there are important variations in the structures
of the different practice plans Some practice plans maintain each department
in individual financial silos; each department keeps its own profits but also
is responsible for any losses These practice plans do not cost-shift to support underperforming departments or specialties that receive poor remunerations for providing their services Thus, although a neurosurgeon may have a yearly salary
of $1,000,000, a general internist in the same institution may have a salary of
$100,000 per year despite the fact that the neurosurgeon receives many referrals from colleagues in internal medicine or that the internist provides the postopera-tive care for the neurosurgical patient
This nonintegrated approach to practice plan management is very effective at maintaining the high revenues accrued by some specialists, including neurosur-gery, orthopedic surgery, ophthalmology, and ear, nose, and throat However, it disadvantages physicians who do not perform procedures and work at the lower end of the economic ladder, including general internists and family physicians
It is not surprising that under this model it is becoming increasingly difficult to recruit and retain general internists
At the other end of the spectrum are practice plans that operate as tispecialty group practices Under this model, decision making occurs at the group level, resources are shared across the various practice specialties, and there is transparency among the multiple elements of the practice plan—much like the operations in a successful business However, the totally integrated multispecialty group practice model exists at only a relatively few AMCs, including the Mayo Clinic, an institution where this type of culture has existed for decades
mul-The multispecialty group practice model provides an opportunity for nal cost sharing and supports the recruitment and retention of outstanding clinicians in all fields As one might imagine, moving from one end of the spec-trum (independent practice plan units) to the other end (multispecialty group practice) is a herculean task Any restructuring efforts are immediately impeded
ratio-by the entrenched economic culture of most organizations and the fear of many
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specialties that restructuring will cut into their economic status Nonetheless, common sense would suggest that, like a business, an AMC could operate most efficiently if the many departments were integrated in a logical fashion As we will see later in this chapter, clinical care service lines may provide an answer to these challenges
types of Integration
Scholars in the fields of business management and economics have defined two forms of integration across business entities: vertical and horizontal integration Vertical integration has been defined as the degree to which a company owns its upstream suppliers and its downstream buyers [4] In the AMC, vertical integration brings together all of the different specialties that participate in the global care of a patient with a given disease and therefore includes specialists who receive large remunerations for providing their services, as well as those who receive limited remuneration For example, a vertically integrated vascular center would include vascular surgeons, interventional radiologists, and inter-ventional cardiologists, as well as general internists trained in vascular medicine who might opt to treat the patient medically before pursuing surgical or inter-ventional options
It makes intuitive sense that from the standpoint of patient care, having all
of the appropriate physicians in the same place at the same time, with a common support staff and apparatus, provides the best opportunity to deliver seamless and safe care to patients with any given disease However, because the various groups that participate in a vertically integrated system have very different levels of remu-neration and provide different skills, the challenges to implementing vertical inte-gration are great, resulting in few AMCs pursuing this level of integration
By contrast, horizontal integration occurs when a business takes over a group
of competing companies that provided the same services In an AMC, horizontal integration among different clinical departments would consist of the integration
of physicians whose levels of reimbursement are approximately the same, who perform similar diagnostic or therapeutic techniques, who have similar cultures
or personalities, and who utilize the same—usually expensive—institutional resources Steven Levin, a healthcare consultant, has recently referred to this type
of academic integration as “lateral” integration [5] Examples of lateral integration include the development of sleep disorder centers by neurologists, pulmonolo-gists, and psychiatrists; development of spine centers by orthopedic surgeons and neurosurgeons; and the creation of vascular centers by neurosurgeons, interven-tional radiologists, cardiologists, vascular surgeons, and neurologists