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Academic Medicine:
doi: 10.1097/ACM.0b013e3181722c7c
Institutional Issues

Development and Implementation of a Comprehensive Strategic Plan for Medical Education at an Academic Medical Center

Schwartzstein, Richard M. MD; Huang, Grace C. MD; Coughlin, Christine M. EdM

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Author Information

Dr. Schwartzstein is executive director, Center for Education, Carl J. Shapiro Institute for Education and Research, vice president for education, Beth Israel Deaconess Medical Center; and faculty associate dean for education and professor of medicine, Harvard Medical School, Boston, Massachusetts.

Dr. Huang is director of assessment, Carl J. Shapiro Institute for Education and Research; and assistant professor of medicine, Harvard Medical School, Boston, Massachusetts.

Ms. Coughlin is associate director, Center for Education, Carl J. Shapiro Institute for Education and Research, Boston, Massachusetts.

Correspondence should be addressed to Dr. Schwartzstein, Center for Education, Carl J. Shapiro Institute for Education and Research, Beth Israel Deaconess Medical Center and Harvard Medical School, 330 Brookline Avenue, E/ES-216, Boston, MA 02215; telephone: (617) 667-5864; fax: (617) 667-9122; e-mail: (rschwart@bidmc.harvard.edu).

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Abstract

Despite their vital contributions to the training of future physicians, many academic teaching hospitals have grown operationally and financially distinct from affiliated medical schools because of divergent missions, contributing to the erosion of clinical training. Some institutions have responded by building hybrid organizations; others by creating large health care networks with variable relationships with the affiliated medical school. In this case, the authors wished to establish the future educational mission of their medical center as a core element of the institution by creating data-driven recommendations for reorganization, programs, and financing. They conducted a self-study of all constituents, the results of which confirmed the importance of education at their institution but also revealed the insufficiency of incentives for teaching. They underwent an external review by a committee of prominent educators, and they involved administrators at the hospital and the medical school. Together, these inputs composed an informed assessment of medical education at their teaching hospital, from which they developed and actualized an institution-wide strategic plan for education. Over the course of three years, they centralized the administrative structure for education, implemented programs that cross departments and reinforce the UME–GME continuum, and created transparency in the financing of medical education. The plan was purposefully aligned with the clinical and research strategic plans by supporting patient safety in programs and the professional development of faculty. The application of a rigorous strategic planning process to medical education at an academic teaching hospital can focus the mission, invigorate faculty, and lead to innovative programs.

The three core values of the academic medical center are the delivery of clinical services, the creation of new knowledge through research, and the education of the next generation of physicians. In practice, however, medical education does not always represent an equal partner in the enterprise of the teaching hospital, whose mission, finances, and governance are in many instances distinct from those of its affiliated medical school.1 Efforts to reconcile these divergent goals in the face of a difficult economic climate have resulted in hybrid models, as well as mergers, “demergers,” and reliance on management strategies developed in the corporate world.2–4 Whatever the organizational arrangement, there still exists a tendency for the educational mission to take a backseat to the clinical and/or research enterprises at academic medical centers.5

While clinical and research activities bring revenue to the hospital and largely form the basis for the medical center’s position in the marketplace, education relies predominantly on fixed federal reimbursement for residency training and traditionally very small contributions from the medical school that, even together, are not sufficient to cover the costs of teaching medical students, residents, and fellows. Cross-subsidization of educational activities with dollars earned in clinical care is increasingly threatened by narrowing profit margins.6 Furthermore, hospital administrators often view time spent on teaching as competing with the more important and financially more remunerative activities in clinics and laboratories. Changes in reimbursement policies and new technologies have led to reduced lengths of stay and therefore greater challenges to faculty to deliver to students and residents a set of clinical experiences that portray the range of issues encountered during the evaluation and treatment of disease. Taken together, these factors have tended to relegate clinical education and faculty support for teaching to the no-man’s land between the medical school and medical center.

The Beth Israel Deaconess Medical Center (BIDMC) embarked on an institutional strategic review of the educational mission in the summer of 2003. BIDMC had already completed analyses of its clinical and research programs but recognized that education may ultimately be at the center of all the challenges confronting the academic medical center. A strategic review of education gave substance to the rhetoric that the medical center truly has three key missions. We describe here the methodology employed in the strategic review of education at BIDMC in 2003–2004, the recommendations that emanated from this review, and the results that followed in the ensuing three years. In doing so, we document how we applied the same rigor in the strategic planning process used for clinical services and research to medical education at our academic teaching hospital.

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Methods of the Strategic Analysis: Self-Study, External Review, and Governance

Overview

In 2003, the medical center’s chief executive officer and chief academic officer charged the director of graduate medical education (R.S.) with the responsibility of directing a strategic analysis of all medical education at BIDMC. The first action was to create a coordinating committee, composed of leaders in undergraduate and graduate medical education as well as administrative leaders from BIDMC and Harvard Medical School (HMS), to provide oversight of the review process. A separate survey committee designed the tools necessary for the self-study portion of the process. We invited four national experts in medical education who, together, formed the visiting committee and provided an external perspective on the medical center’s strengths and areas in need of improvement. We convened subcommittees on finance, undergraduate medical education (UME), and graduate medical education (GME) to assist with the self-study and to formulate recommendations. Participation on the committees was voluntary, without reimbursement.

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Self-study

To ensure that we obtained information from all relevant educational constituencies, we conducted four separate Web-based surveys in October 2003 that targeted HMS medical students, residents/fellows, faculty, and division/department chiefs. A team of researchers from BIDMC, Harvard School of Public Health, and Cogent Research developed the surveys, tailoring them to each constituent group, and designing them to require only 10 minutes to complete. We sent an e-mail to all BIDMC-based faculty and trainees and to all HMS medical students who had participated in educational programs at BIDMC. The solicitation e-mail outlined the importance of constituents’ input in the development of a new strategic plan for education and included a link to the Web-based survey. We sent one reminder e-mail to all eligible respondents over the course of the seven days that we administered the survey. The surveys included questions on

* the quality of teaching,

* curriculum,

* interdepartmental programs,

* physical space for education,

* teaching funds,

* faculty development,

* technology in education, and

* the transition from undergraduate to graduate medical education.

Appendix A summarizes additional topics covered by the survey questions. Questions predominantly used five-point Likert scales, and at the end of each survey we elicited open-text responses about strengths and weaknesses of the hospital’s educational enterprise and recommendations for improvement.

The self-study also included an open “town meeting” to solicit additional input from members of the BIDMC academic community. We distributed a hospital-wide advertisement of the town meeting via e-mail. We held the session, which over 100 people attended, in the medical center’s auditorium on a weekday evening, and the chief academic officer commenced the meeting. The session lasted for 90 minutes, during which time individuals representing the faculty, social work and nursing departments, and hospital administration contributed to the discussion.

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Visiting committee

The visiting committee consisted of four nationally recognized leaders in medical education: Lewis Landsberg, MD, then dean and vice president for Medical Affairs, Feinberg School of Medicine, Northwestern University; Ruth-Marie Fincher, MD, vice dean, Academic Affairs, Medical College of Georgia; Stephen Leapman, MD, executive associate dean for Educational Affairs, Indiana University School of Medicine; and Michael Whitcomb, MD, then senior vice president, Division of Medical Education, Association of American Medical Colleges. Over the course of three days in December 2003, the members of the visiting committee reviewed the self-study materials and results, held focus groups with all constituent groups (students, residents/fellows, faculty, and division/department chiefs), and toured educational facilities. The focus groups included all visiting committee members, who collectively determined the questions they wished to ask. The visiting committee then created summary recommendations of their findings.

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Internal committees

We invited the members of internal committees based on their roles and responsibilities. The finance subcommittee consisted of the dean for medical education, the hospital chief operating officer, the chief academic officer, and the director of GME reimbursement. We also selected several department chairs to serve on the finance subcommittee based on the size of their departments and their interest in education. The UME subcommittee consisted of all the core clerkship directors, and the GME subcommittee included all of the residency program directors. After the self-study portion of the review, each of the subcommittees met regularly for three months and prepared recommendations that the coordinating committee subsequently reviewed.

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Results of the Analysis and Creation of Recommendations

Self-study

Total respondents numbered 610, for an overall response rate of 37%. Participants in the survey comprised 64 of 164 (39% response rate) medical students who had rotated at BIDMC, 214 of 543 (39%) residents and fellows, 313 of 881 (36%) faculty members, and 19 of 47 (40%) division/department chairs. Additional characteristics of the respondents are detailed in Table 1.

Table 1
Table 1
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Table 1
Table 1
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The surveys for each respondent group ranged from 40 to 69 questions in length. Because of the extensive nature of the survey, we report select results that are reflective of a group of related questions and relevant to the department or the institution as a whole. We do not report results related to curricular structure, perceptions of BIDMC- and HMS-specific entities, or additional demographic details, but those data are readily available on request.

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Medical students and residents/fellows.

Medical students’, residents’, and fellows’ responses confirmed the quality and importance of education at BIDMC. In particular, most student respondents either agreed or strongly agreed that BIDMC faculty were committed to teaching medical students (89%), that residents and fellows were committed to teaching medical students (75%), that the hospital environment was conducive to learning (86%), and that the educational facilities accommodated their learning needs (82%). Medical student respondents cited faculty as the major strength of their clerkship experiences. Residents and fellows also cited faculty and other trainees as major strengths of the training program and the lack of time and opportunities for educational activities (in contrast to clinical obligations) as major weaknesses.

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Faculty.

Faculty respondents reported spending more time teaching residents (73%) compared with time spent teaching medical students (30%) and fellows (45%), and 40% of faculty reported receiving compensation for teaching. The majority of respondents either agreed or strongly agreed that the educational program at BIDMC was a very important factor in their decision to work at the medical center (73%), that the quality of the residents and fellows was an important factor in their decision to join the faculty (86%), that they were encouraged to teach by their division/department chiefs (76%), and that being a teacher was an important aspect of professional self-identity (89%). A minority of respondents either agreed or strongly agreed that they felt like integral members of their medical school (30%), that teaching was an important consideration in academic promotion (32%), that they were aware of how teaching money is allocated within the division/department (17%), and that they received adequate financial support for teaching from their division/department (18%). Among free-text responses to the item, Enumerate the greatest challenges facing education at BIDMC, the faculty identified the lack of incentives or reimbursement for teaching (40%), the lack of protected time for teaching (39%), and the difficulty of balancing clinical obligations with teaching (24%).

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Division/department chiefs.

Most respondents agreed or strongly agreed that their divisions/departments received funds for medical student, resident, and fellowship teaching (68%, 79%, and 63%, respectively), but most disagreed that the funds were adequate (89%, 74%, and 68%, respectively). Most chiefs (74%) felt that when faculty teach, they (the faculty) forgo clinical revenue. Half (53%) disagreed that their faculty had financial incentives for teaching, and half (47%) agreed that BIDMC should commit more resources to education. The majority of respondents either agreed or strongly agreed that teaching was an integral component of promotion decisions (90%), that the medical school considered quality and quantity of teaching in promotion decision (53%), and that educational programs should be better integrated across departments at BIDMC (68%). Division/department chiefs identified as the greatest challenges for education at BIDMC the lack of incentives or reimbursement for teaching (63%), the lack of physical space for teaching (32%), and the lack of protected time for teaching (26%).

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Strategic recommendations

Using recommendations from the visiting committee and results from the self-study, the coordinating committee identified the following key needs: (1) faculty development across departments, (2) teaching incentives for faculty, (3) improved educational space, (4) improved medical student education with more formal teaching, increased direct observation, and increased feedback to medical students, (5) centralized allocation of educational monies, and (6) centralized educational administration. The final recommendations from the coordinating committee collectively addressed these needs (See Table 2) and represented major changes in three domains of medical education at BIDMC:

Table 2
Table 2
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* Infrastructure—the creation of a centralized structure to organize, integrate, support, and supervise the varying elements of the educational mission;

* Programs—the development of a cohort of resource faculty, enhanced professional development, interdisciplinary educational experiences, a comprehensive simulation center, and improved evaluation of the elements of the educational mission; and

* Finances and resources—the institution of mechanisms to ensure the transparency of and accountability for the allocation of educational funds, the development of a comprehensive space plan for education, and the creation of targeted philanthropy to assist in the support of the educational mission.

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Implementation and Evaluation

To assess the state of medical education at BIDMC and to address challenges common to many academic medical centers throughout the nation, we initiated a yearlong review of, and planning process for, educational reform at our center. The initiative included a self-study of constituents at all levels, an external review by a visiting committee of prominent leaders in medical education, and participation of administrative leadership at the medical center and the medical school. The resulting recommendations form the foundation for a Strategic Plan for Education. We believe these efforts to be one of the first described to explicitly establish education on an equal footing with research and clinical services as core missions of the academic medical center. (A similar strategic process took place at Columbia University Medical Center, encompassing research and patient care in addition to education.7)

Although the findings of the needs assessment are not unexpected, formalization of the review process validated heretofore anecdotal sentiments, allowed us to identify specific deficiencies in need of improvement, and provided the hard evidence required before hospital leaders would lend support to an ambitious undertaking. In particular, the discrepancy between the division/department chiefs’ perceptions and those of their faculty about the transparency of the process for allocating money to support teaching heightened awareness of a key area for improved communication.

Although we had not intended explicitly to do so at the outset, our analysis led to recommendations that could be categorized within the four “frames” outlined by Fincher et al as necessary for developing an infrastructure to support scholarship in teaching.8 Specifically, we addressed (1) the structural frame (infrastructure), (2) the human resources frame (addressed through our programs, such as resource faculty and teaching consultation service, as well as support structures, such as the Office of Educational Technology and the Simulation and Skills Center), (3) the political frame (highlighted under governance and finances and resources), and (4) the symbolic frame. This last frame we addressed both with the entire process of the strategic review, a highly symbolic demonstration of the seriousness with which the medical center administration wanted to address educational issues, as well as with specific programs such as our medical center teaching awards ceremony and our annual education week.

As with the strategic plan that emanated from the process of reinventing the academic medical center, detailed by Kirch and colleagues,2 the product of our analysis was a “concise and practical document” based on a “campus-wide cultural assessment” that led to an “align[ment of] the corporate structure and governance to unify the academic enterprise and health system.” Symbolically, this made it clear that the review was not “for show” but that it led to a concrete working plan that would help both define the educational mission and support the faculty who were instrumental in its future success.

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Implementation

The report derived from the strategic review, which comprised both the results of the self-study and the detailed recommendations of the coordinating committee, was presented to the medical center’s board of directors in July 2004. BIDMC senior leadership endorsed, and the board of directors unanimously approved, the report. At the core of the organizational changes and program recommendations emanating from the review was a vision to place BIDMC in a position of strength with respect to innovation in curriculum, professionalization of the teaching faculty, and a greater focus on the spectrum of medical education from medical school to residency training with particular attention to important transition points.

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Infrastructure.

The medical center created the position of vice president for education (VPE), who reports to its chief academic officer, is charged with oversight for all aspects of medical education activities at BIDMC, and serves as faculty associate dean for education at HMS. Figure 1 represents the organizational structure for educational administration at BIDMC as related to HMS. The VPE heads a new Center for Education, which represents the centralized administrative structure for medical education. This center consists of an Office of GME, an Office for UME, the Simulation and Skills Center, and the preexisting Shapiro Institute for Education,9 which provides the support structure for UME and GME through its multiple centers (Center for Faculty Development, Center for Professional Development, Office of Educational Research, Office of Educational Technology). Figure 2 represents the new organizational structure for medical education at BIDMC.

Figure 1
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Figure 2
Figure 2
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The VPE is a member of the medical center’s Operations Council and Medical Executive Committee. In this role, the VPE advocates for educational programs and ensures that decisions regarding clinical, budgetary, and space issues are made with appropriate consideration for the needs of the training programs. Furthermore, as a member of these key administrative branches, the VPE is able to ensure that the annual operating plan of the Center for Education supports the goals and objectives of the medical center, a critical requirement for sustaining financial support in the present fiscal climate. In addition, we charged the VPE to work with each clinical chief to develop departmental models for teaching and plans for allocation of GME funds in concert with those models. The departmental and division chiefs fully implemented these models in academic year 2007 and are making the results available to faculty to ensure they are aware of, and understand the uses of, educational funds. With a dual administrative role at the medical school and medical center, the VPE is able to coordinate in a meaningful way UME and GME programs.

As a member of the Academy at HMS (a formal society of HMS scholars chosen by competitive selection), the VPE has created the first “branch” of the Academy at a Harvard teaching hospital. Resource faculty members (see below) are appointed associate members of the Academy at HMS and the first members of the BIDMC Academy.

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Programs.

In highlighting several of the many programs created under the Strategic Plan for Education, we have focused on those that benefited from centralized oversight for education, thereby enabling successful interdepartmental collaboration, fortification of the UME–GME continuum, and increased support for faculty development. In addition, these programs explicitly address the need identified by all constituents to increase time dedicated to teaching.

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Resource faculty.

To address the need for improved faculty development, we adopted a “core faculty” model to bring faculty development to the clinical departments. We modeled the resource faculty development program after our Rabkin Fellowship in Medical Education10 in that we provided a curriculum in educational theory, discussed sentinel articles and research in medical education, and gave them opportunities to practice teaching skills with peer feedback. Resource faculty serve as liaisons from the Center for Education to individual departments to enhance professional development activities throughout the medical center. Stipends from BIDMC, HMS, and the Shapiro Institute support resource faculty whose nomination by department chairs additionally ensures that they are provided with dedicated time for teaching and professional development. These faculty participate in monthly sessions to improve their own skills as teachers, develop department-specific curricular materials, serve as peer reviewers for other teachers in the medical center (via a formal teaching consultation service started in March 2006), and assist faculty in their departments with academic promotion along the clinician–educator track.

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Principal Clinical Experience.

To address the need to improve medical student teaching, we designed a longitudinal program for third-year medical students that serves as one of the experimental pilots for the ongoing curricular reform effort at HMS.11 In the Principal Clinical Experience (PCE), students spend their entire academic year at BIDMC rotating through traditional core clerkships along with non-PCE students. Basing these students at a single site with a core faculty member responsible for their total development for the year allows us to address challenges in clinical training such as fragmentation of faculty relationships, lack of longitudinal assessment, poor tracking of developmental needs, and insufficient time for learning. Students participate in an intensive, weeklong transition course at BIDMC before beginning their clerkships. The program also provides a longitudinal curriculum that includes, among other elements, (1) case conferences that encompass discussion of humanistic as well as clinical issues, (2) yearlong ambulatory care preceptorships, (3) an interdisciplinary, longitudinal curriculum that integrates basic and clinical sciences in a tutorial format, (4) computer-based and mannequin-based simulation exercises, and (5) structured assignments in case-based and reflective writing.

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Simulation and Skills Center.

To enhance residency and medical student education and to address authentic skills assessment, we established a medical simulation center that is codirected by an anesthesiologist and a surgeon and that serves as a resource for all departments within the medical center. The simulation center integrates multiple types of medical simulation into interdisciplinary curricula designed to teach and assess management in acute emergencies, team-based interactions, and procedural skills. Our expectation is that the simulation center will improve quality of care, reduce medical errors, and enhance working relationships among physicians, nurses, and clinical staff, thereby serving as a concrete example of the ways in which the educational mission can support the clinical mission of the medical center, through, for instance, programs on central line placement and team training for acute crisis management. The simulation program is firmly entrenched within the Center for Education, which provides support for curriculum development and assessment. This organizational structure was a key element in the center’s designation as a Level I American College of Surgeons accredited educational institute.12

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Education Week.

We have established an annual event that commemorates medical education at the hospital, entitled “Education Week: A Celebration of Education at BIDMC.” In June 2006, programs included education grand rounds, the official opening of the Simulation and Skills Center, resident research day (poster and oral presentations of selected abstracts from residents and fellows), a symposium celebrating our fellowship in medical education (a reunion of Rabkin fellows and talks from featured alumni), and a teaching award ceremony held in a large public space to ensure the greatest visibility for the entire BIDMC community. In 2007, in addition to the activities outlined above, we instituted a visiting professorship in medical education. The visiting professor spent several days at BIDMC and HMS, spoke at education grand rounds, met with faculty and medical education fellows to discuss ongoing projects, and counseled individuals and departments interested in education.

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Web-based modules for the Accreditation Council for Graduate Medical Education competencies.

To improve resident education in the Accreditation Council for Graduate Medical Education (ACGME) competencies, we commissioned faculty to develop Web-based modules on systems-based practice and practice-based learning and improvement. The faculty designed these modules for use by residents across departments, and the modules allow us to document compliance with the ACGME mandates.

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Office of Educational Technology.

In 2004, the Center for Education created an Office of Educational Technology, extending the institute’s pioneering work on virtual patients.13 The office is responsible for the development and implementation of Web-based educational resources for the Shapiro Institute and provides consultative services for faculty interested in multimedia programs.

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Office of Educational Research.

In July 2006, the Center for Education created an Office of Education Research to aid and augment the center’s educational research activities. Two individuals (1.25 FTE) with doctoral training in cognitive psychology and sociology staff this office. In addition, they have also assisted other faculty in study design, IRB issues, grant writing, and statistical analysis. In its first 12 months, the office assisted in the submission of six education grants.

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Faculty scholarship.

Scholarly activities emanating from the Center for Education include 29 presentations to national or international audiences, 26 abstracts and posters, 13 published articles, three book chapters, and a textbook. These activities highlighted research from the Center for Professional Development, the Office of Educational Research, the Office of Educational Technology, the Office of GME, and the Simulation and Skills Center.

The focus of the work featured BIDMC programs such as the PCE and the Web-based ACGME modules, and the work of the resource faculty through the Center for Education. Coauthorship by individuals in many different offices and centers within the Center for Education demonstrates the ease of collaboration that the organizational structure has provided.

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Finances and resources.

The consolidation of administrative and support structures for the education mission has enabled us to achieve significant efficiencies compared with the preexisting model in which each department had to provide these services for its own faculty. These efficiencies have also enabled us to provide new programs (Office of Educational Research, Office of Educational Technology, resource faculty, the Simulation and Skills Center) while both strengthening preexisting professional development initiatives and facilitating greater collaboration within several components of the Center for Education. For example, the Office of Educational Research supports not only the GME office and program directors in the development of assessment tools, but also the Office of Professional Development in the teaching of critical thinking skills. Additionally, the Office of Educational Technology equips programs across the Center for Education with technical development support, such as computer-based simulation in the Simulation and Skills Center, Web-based resources for the PCE students, and GME administrative applications. Funding for these programs has come from three sources: philanthropy, HMS, and BIDMC. In particular, the hospital’s support of the Center for Education originates from the annual operating budget. The success we have had in the three years (2005, 2006, 2007) since completion of the strategic review has encouraged a major new seven-figure pledge from a donor to partially support the program expenses for the next 10 years. The link of educational programs to elements of the medical center’s annual operating plan, particularly with respect to patient safety initiatives, has strengthened our ability to justify using operation revenues from the medical center’s budget. For example, a simulation training program for residents that is focused on central venous catheter placement aims to reduce complications, and our clinical triggers (formalized rapid response to clinically deteriorating patients) program for resident trainees has reduced unanticipated cardiac arrests.14–15 As our Office of Educational Research has grown, we have secured grants to support some of our programming, and we are developing additional grant applications. This year, we will offer two continuing medical education courses for which attendees will pay tuition. Our 2007 fiscal year operating expenses, including all programs noted above, were approximately $1.9 million. We believe the structure and programs we have created will provide us with the best opportunities to define and achieve outcomes that all constituents will perceive as educationally meaningful and that department chairs, the medical school dean, and the medical center leadership will understand as adding value to our collective enterprise.

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Barriers to implementation

The process we followed during the strategic review enabled us to build a consensus among critical members of the medical center community. The unanimous vote of the BIDMC board of directors in support of the recommendations emanating from the review provided validation of BIDMC’s commitment to the educational mission. Nevertheless, some still resisted the implementation of those recommendations.

Creation of a central administrative structure for education and the proposal to create greater accountability for, and transparency in, the allocation of teaching funds threatened the autonomy of the department chairs. Similarly, some parties viewed with skepticism and, on occasion, disdain the efforts to bring together previously independent clerkship directors and to require more explicit outcome measures for both the undergraduate and graduate medical education programs. Underlying much of the early opposition were two major concerns: loss of prerogatives, and a fear that reallocations to other programs would compromise resources. Over time, we addressed these concerns by showing that our analyses, proposals, and programs would ultimately provide greater support to faculty and directors, generate new resources (both financial and personnel), rationalize a reward system previously viewed as arbitrary, and enhance the visibility and value of the educational efforts of all faculty. One example of how faculty members reap the benefits of the strategic plan implementation is that the VPE must approve the departmental models for financing teaching activities. This process has focused the attention of the department chairs, in many cases, on the explicit manner in which teaching is provided and on the faculty who provide the teaching. Additionally, the resource faculty have flourished as a group, providing support, guidance, and insights for each other’s projects. We are beginning to see interdepartmental collaborations as well. For example, members of the departments of orthopedics and general surgery are beginning work on the assessment of intraoperative teaching, and the resource faculty from general surgery and psychiatry have held joint rounds with surgical residents. Personal meetings between the VPE and the more recalcitrant members of the BIDMC community to hear concerns, answer questions, dispel rumors, and make clear that there were no hidden agendas were particularly useful. The VPE met frequently with the department chairs throughout the implementation phases of the plan to ensure a sense of collaboration and to demonstrate the benefits to their department of the programs offered. As resource faculty, in particular, flourished in their new roles, the initial doubts and fears of department leaders diminished. In hindsight, we would have included an early institution-wide evaluation of GME programs, given the prominence of these programs in the recommendations of the strategic review, but we are tackling this initiative currently.

Our efforts to build interdepartmental programs and, via our resource faculty initiative, to gain allies within each department, enabled us to build support from many sources, employing clinical colleagues who were often the greatest doubters. Throughout the implementation phase, we never lost sight of the goal of adding value to the lives and work of our educators, our departments, and the medical center.

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Future endeavors

The realignment of our educational mission would be incomplete without a systematic evaluation of our efforts. We are embarking on a hospital-wide survey of our faculty about their perceptions of the new financing schemes for medical education. We continue to maintain a database that tracks the scholarly activities of faculty affiliates of the Center for Education to document the growth of scholarship since the implementation of our plan. As mentioned above, we are conducting an extensive evaluation of our GME programs using metrics explicitly aligned with the clinical mission in patient satisfaction and safety. With respect to links between education and the research missions, the strengthening of the educational program offered by the medical center helps attract top trainees, some of whom ultimately take positions in the laboratories of our faculty. In addition, during the development of a recently submitted Harvard Clinical and Translational Science Award application, the applicants consulted the VPE about the educational component of the grant; we anticipate a greater role for the Center for Education in the preparation of researchers in the future. Lastly, we are an integral part of hospital strategic planning and implementation; in addition to the VPE’s involvement in core administrative decisions, our hospital’s goals serve as the guidepost in determining the ultimate impact of our center’s programs and research, and the newly initiated medical center capital campaign will prominently feature our educational programs and needs.

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Final Perspectives

Academic medical centers are assuming an increasing proportion of the burden of educating trainees as demands on clinical faculty to teach clinical correlations in the basic sciences grow and as the requirements and expectations placed on clinical training become more rigorous. Institutional and program requirements for graduate medical education are expanding at similarly fast rates. We have provided an example of how a formal, institution-wide review of the educational mission can focus goals and generate support for a reevaluation of the academic medical center’s role in producing future generations of physicians. Ultimately, the recommendations arising from the review and the programs implemented addressed the four essential elements of an organizational structure for education, as outlined by Fincher et al: an explicit administrative structure, human resources, political issues, and symbolic concerns.8 Although the specific details of such an analysis and the outcomes resulting from it must vary from one institution to another according to the particulars of the culture, politics, faculty, and resources of the local environment, there is much to be gained from the effort—the hills to climb seem less steep, the burden less heavy, and the challenges confronting medical education more manageable.

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Acknowledgments

The authors gratefully acknowledge Carol Hughes of the Carl J. Shapiro Institute for Education and Research at Harvard Medical School and Beth Israel Deaconess Medical Center for critical administrative support of the processes outlined in this document from beginning to end.

Catherine DesRoches, PhD, of the Harvard School of Public Health, and Cogent Research were compensated as consultants for methodological design of the self-study, data collection, and data analysis.

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Disclaimer

Dr. Michael Whitcomb was a consultant on this project. He reviewed self-assessment survey materials and helped conduct focus groups of constituents at Beth Israel Deaconess Medical Center. He was not involved with the final decision to publish this article.

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References

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