Transcript Faculty Value: How do we measure it?

Faculty Value:
How do we measure it?
Margaret M. Grimes, M.D., M.Ed.
Department of Pathology
Why is this an issue?
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“Despite its fundamental importance, the
educational mission of most medical schools
receives far less recognition and support than do
the missions of research and patient care.”
Irby DM et al. Acad Med 2004;79:729-36
How did we get to this point?
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Medical schools are faced with greater reliance on
clinical revenue and increasing competition for research
funding
Respond by recruiting faculty dedicated primarily to
patient care and education
Thomas PA et al. Acad Med 2004;79:258-264
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“The growing emphasis on delivery of clinical services
and the concomitant decrease in time for tenured and
clinical-educator faculty to teach and do scholarly work
jeopardizes both the potential for continued discovery
and the education of the next generation of medical
scholars..”
Barchi et al Acad Med 2000;75:899-905
Martin GJ et al. EVUs: Development and implementation at two different
institutions. www.im.org/.../
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“Most faculty want to teach- but think twice when it reduces their income
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Increasingly difficult to find faculty for resident interviews, physical
diagnosis, clerkship lectures, etc.
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Same faculty always volunteer, leading to decreased diversity in teaching
programs
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Decreased faculty enthusiasm about teaching impacts student career
choices
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Faculty held accountable to meet (clinical) productivity targets; faculty no
longer want to teach because it will cost them in…salary.”
Cascading problems
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Research funding declining
Departments place increased value on clinical dollars
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Faculty hired for clinical service (and teaching)
Educational funding variable/not clearly linked
Clinical time trumps education time
Faculty members who teach outside of their
departments return relatively little in direct benefits
to the department regardless of benefit to the school
Traditional promotion and tenure favors scholarship
Faculty expected to teach without necessarily
knowing how
So, why do we choose to teach?
(or choose to work in an academic setting?)
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Personal satisfaction
Role models
Intellectually stimulating environment
?Peer/student recognition
Comes with the territory
“They make me do it”
What are ways in which teaching faculty might be
valued?
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Teaching as an avenue for career
advancement?? (personal)
Linking teaching and $$??
(departmental/personal)
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Career advancement??
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Clinician-educator faculty are increasing in
numbers but their advancement is slower than
that of research faculty
 Lower rank at hire
 Limited time available for scholarly effort
 Limited resources
Thomas PA et al. Acad Med 2004;79:258-264
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Promotion and tenure:
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Scholarship
Teaching
Clinical effort/expertise
Regional/national recognition
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AAMC Group on Educational Affairs
 Re-affirmed 5 education activity categories:
 Teaching
 Curriculum
 Advising/mentoring
 Leadership/administration
 Learner assessment
 “The establishment of documentation
standards for education activities provides the
foundation for academic recognition of
educators.”
Simpson et al. Med Educ 2007;41:1002-9
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Scholarly approach = demonstrating evidence of
drawing from and building on the work of others
Scholarship = contributing work through public
display, peer review and dissemination
Engagement with the education community
“Educators’ contributions to their institutions must
be visible to be valued.”
Simpson et al. Med Educ 2007;41:1002-9
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Single-track vs. two (or more)-track
systems
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Problems:
 Elitism
 Expectations may constrain initiative
 Scholarship and national recognition still
expected
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Faculty development
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Teaching skills
Technology
Educational community
Scholarship
Other forms of recognition…
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Schindler et al: Recognizing clinical faculty’s
contributions in education. Acad Med 2002; 77:940-1
Faculty productivity profile system to recognize administrative,
educational and research activities
Excel document sent to faculty once a year. Committee identified
all possible opportunities as educators (lectures, participating in
faculty development, mentoring, interviewing, administrative,
attending conferences/journal clubs)
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Point scale for each activity 0-25. Faculty fill in number of times –
multiplied by points to give weighted score
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Awards/dinner given for outstanding contributions
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Still left with the problem of
TIME AND MONEY
Teaching Academies
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Irby et al. The Academy Movement (Acad Med 2004)
argues that reform requires fundamental organizational
change. Academies are:
 dedicated to education
 independent but supportive of existing departments
 positioned to offer incentives and support, promote
the scholarship of teaching, and encourage
curriculum innovation
 have dedicated resources that fund mission-related
initiatives
 do not compromise departments’ ability to succeed
in research or patient care
“Academies serve as powerful symbols of the
importance and centrality of education.”
Educational Dollars:
Where do they come from?
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Undergraduate
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State appropriation
Tuition
Grants and contracts
PRACTICE PLANS
GME
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Federal: CMS
 Direct
 Indirect
State (in Virginia, only for Family Medicine)
Tracking Teaching Effort:
Why Develop a Metric?
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Six broad rationales:
Mallon and Jones. Acad Med 2002;77:115-123
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Develop rational method for distributing funds to
departments
Track resources spent on teaching/educational activities
“Address department chairs’ mistrust of dean’s office
about hidden money”
Counteract the myth that faculty cannot afford to teach or
are not compensated to do so
Provide an incentive to faculty to participate in current or
expanded educational activities
Make the educational mission more visible
How do medical schools use measurement systems to track
faculty activity and productivity in teaching?
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Mallon and Jones
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41 schools surveyed for teaching metrics
Two main methods identified: contact hours and
RVUs
Contact hours:
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(Acad Med 2002;77:115-123)
Some models allocated an additional amount of
time to account for preparation and evaluation
Some models counted actual contact hours only
RVU method
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Assigned each teaching activity a relative weight
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Resource-based relative value scale (RBRVS)
 Used by Medicare to determine how much medical
providers should be paid
 Assigns a relative value to procedures, adjusted by
geographic region
 Multiplied by a fixed conversion factor (changes annually)
to determine payment
 Prices are determined based on physician work (52%),
practice expense (44%) and malpractice expense (4%)
 RBRVS does not include adjustments for outcomes,
quality of service, severity or demand.
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Procedures categorized by CPT code
Each code assigned a Relative Value, expressed as RVUs
Relative Value Units can be used to track clinical
productivity
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Teaching efforts can be assigned a “relative value”
Track and align with departmental funds
Account for faculty productivity
“Like clinical complexity, teaching complexity
possesses four components: time; educational
value; labor intensity, and degree of patient risk
and responsibility assumed.”
Yeh and Cahill. J Gen Intern Med 1999;14:617-621
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Challenges:
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Lack of culture of using data in management
Skepticism of faculty and chairs
Misguided search for one perfect metric
Expectation that metric will eliminate ambiguity
about teaching contributions
Lack of measures of quality
Tendency to become overly complex
Mallon and Jones. Acad Med 2002;77:115-123
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Yeh and Cahill 1999: Designed 3 step process for calculating
teaching productivity based on RVUs:
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Teaching Value Multiplier (TVM) addressed the differences
in complexity of various teaching tasks. TVM is a ratio
describing the worth on a given unit of time spent
teaching relative to the equivalent amount of time spent
on clinical activities.
RVU generated through teaching = TVM x time required
by activity x regional median clinical RVU productivity rate
(#RVUs per hour).
Related all RVU calculations to the regional RVU
production rate to ensure that teaching physicians would
be compensated at no better or worse than the median
rate for other area physicians.
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A few institutions reallocated resources based on
the metrics
More often, the outcome was increased attention
to the educational mission without resource
reallocation
“It puts medical education on the table.”
Mallon and Jones. Acad Med 2002;77:115-123
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1999- Watson and Romrell (U. Fla.) reported
development of a process that came to be known
as “mission-based budgeting”.
3-step process
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identifying revenue streams to fund each of the
institution’s missions
evaluate each faculty member’s productivity with
regard to each mission
align funding source with faculty effort.
Stites S et al. Acad Med 2005;80:1100-1106
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AAMC established a Mission-Based Management (MBM)
Program to aid in the task of realigning funds to match
missions.
The MBM task force for medical education suggested a
template for approaching MBM in education, beginning
with
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listing all faculty educational activities,
assigning each activity a weight in RVU’s
include time to perform function, preparation, level of
expertise, and relative importance of the activity.
Attempt to link compensation to quality of teaching rather
than quantity only.
MBM met with mixed reactions. Resistance to change;
logistical difficulty collecting data.
Educational Value Units (EVU’s)
Stites S, Vansaghi L, Pingleton S et al. Aligning compensation with
education. Acad Med 2005;80:1100-1106
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In 2003, U. Kansas Dept of Internal Medicine created a task force
to develop a teaching metric.
Reviewed faculty Medicare time sheets, historical distribution of
financial support, and educational responsibilities; reviewed
literature.
Task force was concerned about the subjectivity in assigning
weight to various teaching activities.
Goal was development of a new metric that would be:
 easily understood
 have a prospective, goal-setting approach
 an efficient use of faculty time and resources
Decided against RVU metric; chose to create a time-based
metric.
Stites et al. Acad Med 2005
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Educational value unit (EVU) was defined as a unit of
time spent in education of students and residents.
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Avoided subjective assignment of relative values.
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Chose to value different activities with the same metric
regardless of subspecialty or level of experience.
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0.1 EVU represented ~4 hrs work per week. Dollar
value calculated for each 0.1 EVU.
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In theory, the EVU for a particular activity represents
the fraction of the time devoted to purely education
related functions while completing the activity.
Stites et al. Acad Med 2005
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Core and Clinical subdivisions of EVU
Core EVU was defined as teaching time spent
educating students and residents that is not
associated with billable clinical activity (Grand
Rounds, morning report, CPC, small-group with
medical students, all development time for
didactic lecture preparation and presentation;
administration of programs).
 Each faculty member was presumed to
contribute a baseline of 0.2 core EVU while
conducting non-billable clinical activities.
 To be validated during year with recorded logs
submitted by faculty.
Stites et al. Acad Med 2005
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Clinical EVUs were defined as those associated
with billable clinical activities. Could be accrued
automatically based on inpatient and outpatient
attending schedules. Not meant to fully replace
clinical income but to compensate for the
expected decrease in faculty efficiency and
productivity during patient care in the presence of
learners.
An EVU template was developed for each faculty
member, allowing them to determine their
proportion of work and compensation for the
educational mission.
Stites et al. Acad Med 2005
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Hospitalist with 4.5 months inpatient rounding and 2.5
months general medicine consults; also serves as
student clerkship director:
 Clinical EVU
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Core EVU
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Inpt attending: 0.020/month x 4.5 mo = 0.09
EVU = 11,305.80
Consults with resident: 0.015/mo x 2.5 mo =
0.0375 EVU = 4,710.75
Total = 0.1275 Clinical EVU = 16,016.55
Baseline expectation = 0.20 EVU = 25,124.00
Administration = 0.10 EVU = 12,562,00
Total = 0.30 Core EVU = 37,686
Total: 0.4274 EVU = 53,702.55
Stites et al. Acad Med 2005
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57 faculty members had a change in their salary structure as
a result
34 had a decrease in salary support from the university.
23 had an increase.
Overall realignment of 1.66 million.
“A number of faculty who were heavily involved in teaching
were able to decrease their clinical responsibilities, allowing
time for teaching activities while maintaining their salaries.
Those who were less involved had a decrease in university
educational support, and were more dependent on clinical
activities to maintain their salaries.”
Despite shift, application of the metric did not appreciably
change total faculty compensation, but rather created a
realignment of salary sources with the department’s
educational and clinical missions.
Stites et al. Acad Med 2005
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Faculty survey 4 months later: 39% felt educational
productivity would be better, 46% unchanged. Varying
opinion on fairness of dollar amounts.
Dramatic improvement in faculty attendance at Grand
Rounds, CPC and M&M conference. (No evidence of faculty
over-reporting).
This system differs from previously reported metrics:
 Time-based
 Prospective
 Compensates bedside teaching in addition to formal
lectures and program administration.
“Simple system that allowed faculty to self-report their
time spent in educational effort… Established a market
value for an internist’s teaching time, which is not
specialty-specific.”
Stites et al. Acad Med 2005
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EVU system might discourage subspecialists with
higher rates of reimbursement for clinical work from
teaching
Prospective approach allowed leadership to set clear
expectation of teaching productivity by faculty
members. A clinical productivity incentive program
simultaneously implemented.
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The value of the EVU depends on university funding
which can vary from year to year.
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Limitation: no incentive program to measure quality of
teaching effort and adjust compensation accordingly.
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How are we measuring (valuing)
educational effort at VCUHS?
References
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Barchi RL, Lowery BJ. Scholarship in the medical faculty from the university
perspective: retaining academic values. Acad Med 2000;75:899-905
Irby DM, Cooke M, Lowenstein D, Richards B. The Academy Movement: A structural
approach to reinvigorating the educational mission. Acad Med 2004;79:729-736.
Mallon WT, Jones RF. How do medical schools use measurement systems to track
faculty activity and productivity in teaching? Acad Med 2002;77:115-123
Martin GJ et al. EVUs: Development and implementation at two different institutions.
www.im.org/.../Documents/AIM%20Presentations/wkshp%20104educational%20value%20units.pdf
Schindler et al. Recognizing clinical faculty’s contributions in education. Acad Med 2002;
77:940-1
Simpson D, Fincher RM, Hafler JP et al. Advancing educators and education by defining
the components and evidence associated with educational scholarship. Med Educ
2007;41:1002-9
Stites S, Vansaghi L, Pingleton S et al. Aligning compensation with education. Acad Med
2005;80:1100-1106
Thomas PA, Diener-West M, Canto MI et al. Results of an academic promotion and
career path survey of faculty at the Johns Hopkins University School of Medicine. Acad
Med 2004;79:258-264
Yeh MM, Cahill DF. Quantifying physician teaching productivity using clinical relative
value units. J Gen Intern Med 1999;14:617-621