Transformative changes in health economics and care delivery threaten to disrupt the alignment of academic medical centers’ tripartite missions of patient care, research, and education. Increasing emphasis on revenue generation, for example, could jeopardize the fundamental notion of what it means to be faculty. In recognition of this issue, Block et al1 recently suggested a national conversation on the definition of faculty, proposing a framework that includes teaching as a fundamental scholarly obligation of all faculty. They advocate for institutions to define expected thresholds of effort and impact for faculty’s educational endeavors.
Despite being a core mission, education is often marginalized in academic medical departments, and expectations of faculty effort in this area are often vague. In some cases, educational work may be viewed as voluntary—to be undertaken at the individual’s discretion—rather than as a fundamental responsibility. A lack of defined teaching requirements may lead to disparities among the educational services provided by individual faculty members and difficulties in fulfilling the educational mission. This failure to assign and monitor teaching requirements may be partially driven by funding issues. Whereas clinical work and research usually have clear funding streams, with allocations distributed according to effort, funding for education is often indistinct or insufficient.
A potential solution is mission-based budgeting (MBB)—the allocation of resources based on core-mission-related priorities—in which funding, and thus compensation, is aligned with specific, measurable mission-based activities.2,3 MBB helps academic health centers and departments achieve their mission by supporting prioritized, mission-related activities. In the case of education, this entails the establishment of clear requirements for faculty teaching activities related to core departmental educational needs, which not only ensure fulfillment of the educational mission but may also safeguard and clearly define the role of faculty as educators. In this report, we describe the establishment of a system (using an MBB approach) to assign and monitor faculty’s teaching activities related to the core departmental educational mission at the Department of Emergency Medicine, Johns Hopkins Medicine, Baltimore, Maryland, that is generalizable to most academic medical departments.
Full-time faculty in the department had historically been expected to devote a minimum of 5% (approximately 100 hours) of their annual effort to teaching, exclusive of clinical supervision. Part-time faculty and fellows were not expected to meet this full-time requirement, whereas education-focused full-time faculty were expected to contribute at higher levels, but specific expectations were not well defined. Although resident conference obligations had long been monitored and enforced, other teaching requirements were loosely set and largely viewed as voluntary. This led to wide variability in the educational effort spent by individual faculty members, with some faculty members devoting little of their time to it and others expending hundreds of hours each year on it. Additionally, individual faculty members had their own definition of acceptable teaching activities on which to spend their time, and thus educational leaders experienced difficulties in ensuring adequate staffing for some core departmental teaching activities. For example, some faculty focused their attention on prehospital provider instruction, international programs, or graduate courses and then cited not having enough time to participate in programs related to core departmental educational needs. Though worthy, these endeavors did not advance the departmental mission of providing quality education for core learners (medical students and residents).
Our goal was to develop a system of assigning and monitoring teaching activities that (1) distributes teaching efforts related to the core educational mission equitably across faculty, (2) is transparent, (3) ensures a focus on mission-critical priorities, (4) allows faculty self-selection of most and least preferred activities, (5) uses MBB to ensure equal recognition and compensation for the efforts expended, (6) minimizes administrative burden, and (7) is generalizable to other departments and institutions.
To that end, we developed a novel educational value unit (EVU) system, inspired by other models such as the relative value scale in teaching,4 teaching value units,5 and academic relative value units.6 These earlier models recognize educational effort and weigh factors such as the time needed to prepare for the activity and the importance of the activity. These complex models can generate significant administrative burden and potentially create conflict over the relative value of an educator’s work. We therefore developed and implemented a simplified EVU system to assign and monitor faculty members’ teaching efforts.
From December 2012 to March 2013, we developed an EVU system (using an MBB approach) to assign and monitor teaching activities related to the core departmental educational mission at the Department of Emergency Medicine, Johns Hopkins Medicine. See List 1 for an overview of the steps we used to create this system.
Steps Used to Create an EVU Systema to Assign and Monitor Teaching Activities Related to the Core Departmental Educational Mission, Department of Emergency Medicine, Johns Hopkins Medicine
- Discuss the proposed system with core education faculty.
- Conduct an inventory of all core teaching activities.
Determine the total annual faculty teaching effort needed.
- a. Can include essential administrative tasks (e.g., resident selection committee).
- b. Determine which teaching activities will not be considered core and thus not recognized in the EVU system.
- Determine the relationship between EVUs and faculty effort and time (1% effort = 20 EVUs, and 1 hour = 1 EVU).
Determine the total annual faculty teaching effort available.
- a. Calculate the total faculty time required to implement core teaching activities.
- b. Convert the time required into EVUs and tally total annual EVUs needed (see Table 1).
Compare the needed EVUs to the available EVUs.
- a. Calculate the total faculty effort available based on the minimum thresholds for various types of faculty (5% of annual effort or 100 EVUs for full-time faculty, 20% of annual effort or 400 EVUs for faculty with education-focused career path, and 2.5% of annual effort or 50 EVUs for part-time faculty and fellows).
- b. Convert effort into EVUs and tally total annual EVUs available.
Determine the consequences of failure to meet yearly EVU obligations.
- a. If there are insufficient EVUs available to cover core teaching activities:
- i. Consider curtailing some core teaching activities; or
- ii. Increase the percent of effort required of all faculty.
- b. If there is an excess of EVUs available beyond what is needed for core teaching activities:
- i. Consider expanding the range of teaching activities considered to be core; or
- ii. Decrease the percent of effort required of all faculty.
Disseminate a list of core teaching activities and allow individual faculty members to indicate their most and least preferred activities.
Assign individual faculty members to specific core teaching activities and disseminate assignments to faculty.
Monitor faculty participation in core teaching activities through annual reports by teaching activity leaders as well as faculty self-reports.
- a. Carry unfulfilled obligations forward into following year.
- b. Increase clinical (or other) commitment (2:1 ratio suggested).
Abbreviation: EVU indicates education value unit.
aUsing a mission-based budgeting approach.
Determining core teaching activities
Core education faculty vetted the proposed EVU system at meetings in January and February 2013, during which we sought their input regarding which teaching activities should be considered core. We included only those activities deemed essential to the educational mission of the department in our EVU system; other departments wishing to adopt this EVU concept would select their own criteria for inclusion. We specifically targeted the education of core learners, as we felt that educational endeavors related to other learner groups (e.g., fellows), although valuable, were inherent in the obligations of specific faculty and were usually associated with intrinsic rewards, such as mentored publications and institutional recognition, and/or funding, such as grants obtained by the fellow or receipt of designated institutional funds supporting faculty effort. In addition to teaching activities, we included essential administrative activities related to education that were not considered to be part of core residency administrative duties, such as residency interviewing. When there was a dispute as to whether an activity should receive EVU credit, the department chair made the final decision with advisement from educational leadership. Although faculty were encouraged to continue other educational endeavors, only core teaching activities were given credit toward faculty requirements in the EVU system.
Developing the EVUs
Unlike many previously published systems,4–6 we chose learner contact time, regardless of preparation time, the level of the learner, or perceived importance of the activity, as our base unit for EVUs. We decided a single EVU would be equal to roughly one hour of in-person time with core learners.
Despite previous systems describing the standardization of value units for the preparation of learning materials,5,6 in developing our EVU system, we found great discordance in faculty’s efforts and opinions on this matter. For example, no consensus could be achieved on the time needed to create a lecture. We therefore decided that removing the preparation component from the EVU system would allow faculty to expend the effort they felt appropriate on preparations. Similarly, although some prior programs have assigned greater value to the education of residents than to the education of medical students,6 we felt that the education of residents and medical students were both core components of our mission, and thus we valued both equally.
Development of the teaching grid and faculty requirements
In February 2013, educational leaders determined the total annual EVUs needed to complete all core teaching activities, then assessed what the impact of their equitable distribution among the available faculty would be by comparing them with the total annual available EVUs. We determined that to meet our core educational mission, all full-time faculty should earn a minimum of 100 EVUs annually (5% of annual effort), and full-time faculty on education-focused career paths should earn a minimum 400 EVUs (20% of annual effort). We also felt that part-time faculty and fellows should have obligations concordant with the definition of faculty,1 and thus we required a minimum 50 EVUs annually (2.5% of annual effort) for this group.
On the basis of the above distribution, we created the “teaching grid,” a spreadsheet listing all core teaching activities and the EVUs required to complete them. To consider individual preferences and strengths and to maximize enjoyment and success, faculty members were asked to select their most and least preferred activities from this grid and were subsequently matched to educational programs.
Assignment of EVU obligations
Each faculty member was assigned EVU obligations prior to the beginning of academic year 2013–2014 in May, allowing for advanced planning. Faculty were permitted to trade assigned EVU obligations, but all obligations required coverage. At the end of the academic year, educational activity leaders provided annual reports on faculty participation data, which were compiled and discussed during annual review meetings with the department chair. Faculty who were not assigned the applicable minimum threshold of EVUs (see above) or who fell short because of session cancellations or other external factors were not subject to penalty. Faculty who failed to fulfill their EVU obligations (see below) had the shortfall translated to an increase in their clinical obligations or carried forward into their EVU obligations for the following year.
Our system represents a simple form of MBB in that we recognized a deficit between the faculty effort needed to fulfill our educational mission and the teaching activities on which faculty were spending their efforts, developed a metric to quantify faculty effort spent on mission-related teaching activities (i.e., the EVU system), and then allocated funds accordingly. Without a formal compensation or reporting structure, teaching activities were undervalued relative to activities with a transparent compensation source, like clinical work and research, before the EVU system was implemented. To underscore the importance of education to our mission, the department underwrote 5% of the base salary for full-time faculty members (assuming they met their minimum of 100 EVUs) and paid this amount as a supplement. By formally allocating financial resources to our educational mission, we sought to reframe faculty perceptions of teaching, so that it was seen as an integral component of the scholarly expectations of all faculty members, rather than as volunteer work.
The teaching grid distributed 5,896 EVUs among 54 faculty members for academic year 2013–2014 (Table 1). Assigned EVU obligations included 3,942 EVUs for educational contact time activities and 1,954 EVUs for administrative activities related to education (see above). Of the participating faculty members, 26 were full-time faculty, 10 were full-time faculty in education-focused career paths, and 18 were part-time faculty or fellows.
At the end of academic year 2013–2014, complete EVU data were available for 47 faculty members; 7 faculty members did not complete the year for various reasons. Of the faculty that did complete the year, 3 faculty members, all in educational leadership, expended effort greater than 10% of their assigned EVU obligations. However, this burden was significantly less than what these faculty members had experienced prior to the EVU system, demonstrating a more equitable distribution of teaching efforts among faculty.
Of the remaining 44 faculty members who completed the year, 34 had assigned EVU obligations that ultimately required less effort than had originally been accounted for. These discrepancies were due to programmatic overestimation of the EVUs needed and were not considered deficiencies on the part of the faculty members. We defined failure to complete assigned EVU obligations as a deficit of greater than 10% of the adjusted total expected. Using this definition, only 6 faculty members (2 full-time and 4 part-time or fellows) failed to complete their assigned EVU obligations. The maximum deficit for any faculty member was 26%.
Overall, the EVU system was successful in achieving our intervention goals (see above). First, all core teaching activities were covered by faculty as part of the EVU system. More important, the system emphasized the department’s commitment to the educational mission and impressed upon each faculty member that teaching was an essential component of academic life and of being faculty. Educational efforts were distributed more equitably across faculty, with less undue burden falling on educational leaders and more widespread faculty participation. EVUs are readily quantifiable and understandable, leading to a transparent system with greater clarity about expectations and better accountability. Limiting EVUs to mission-critical teaching activities combined with a simple MBB compensation plan ensured the alignment of faculty teaching efforts with departmental priorities. Faculty were afforded a reasonable degree of self-selection of preferred teaching activities, and the standardization of the EVU ensured equal recognition and compensation of teaching efforts. The system proved relatively straightforward to implement, without undue administrative burden or needless complexity. In addition, it is easily translatable to other academic medical specialties and is currently being implemented by a non-emergency-medicine department within our institution. It could also be readily adapted to basic science departments by adjusting the scope and endeavors considered to be core teaching activities.
Although we did not originally include learner outcomes as a formal component of our EVU system, we did continue to follow standard quality metrics for our educational programs. We found no changes in learner satisfaction for any of our educational programs, including those affected by the implementation of the EVU system. In the future, we plan to consider the incorporation of learner outcome metrics specific to the EVU system to ensure that the quality, as well as the quantity, of educational efforts by faculty is adequate.
Refinement of the teaching grid
We do not consider the teaching grid to be immutable. In the first year of the program (academic year 2013–2014), faculty identified three additional areas worthy of EVU recognition, and every year, education leaders review areas needed to sustain the core educational mission and make adjustments accordingly. In addition, as medical education evolves to include new modalities and content areas, the need for efforts devoted to curriculum development may increase. Although we currently confine the EVU system to educational contact time activities and administrative activities related to education, it may become necessary to include activities related to creating novel curricula. We therefore plan to refine the teaching grid as needed.
Failure to meet EVU obligations
Although most faculty members have embraced the EVU system, a few failed to meet their EVU obligations. Repeated failure to meet EVU obligations may jeopardize an individual’s standing as faculty, and consequences should be in place for faculty members who continually refuse or otherwise fail to engage in required educational endeavors. We are incorporating failure to meet EVU obligations into the overall yearly faculty evaluation and adjusting financial bonus calculations accordingly. These steps not only promote broad faculty engagement in core departmental educational needs but also underscore the importance of teaching as a fundamental faculty responsibility.
Dissemination to other settings
The EVU system is readily translatable to other departments and institutions. Departments wishing to institute a similar system would need to identify their own set of mission-critical educational priorities and quantify the total faculty teaching effort needed to implement them. Although we chose to provide financial rewards for engagement in education (paying 5% of full-time faculty members’ base salary as a supplement and making failure to meet EVU obligations part of bonus considerations), nonfinancial incentives (such as peer-group pressure from transparent reporting of effort or reassignment to other tasks, particularly clinical activity, for those failing to meet obligations) may also be effective provided they are salient and meaningful for faculty. Careful monitoring is necessary to ensure appropriate recognition for educational work and to emphasize the integral role of teaching in the academic lives of all faculty members.
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