Faculty Value:How do we measure it?

Margaret M. Grimes, M.D., M.Ed.Department of Pathology

Why is this an issue?

“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?

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

“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/.../

“Most faculty want to teach- but think twice when it reduces their income

Increasingly difficult to find faculty for resident interviews, physical diagnosis, clerkship lectures, etc.

Same faculty always volunteer, leading to decreased diversity in teaching programs

Decreased faculty enthusiasm about teaching impacts student career choices

Faculty held accountable to meet (clinical) productivity targets; faculty no longer want to teach because it will cost them in…salary.”

Cascading problems

Research funding declining Departments place increased value on clinical

dollars 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?)

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?

Teaching as an avenue for career advancement?? (personal)

Linking teaching and $$?? (departmental/personal)

Career advancement?? 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

Promotion and tenure: Scholarship Teaching Clinical effort/expertise Regional/national recognition

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

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

Single-track vs. two (or more)-track systems Problems:

Elitism Expectations may constrain initiative Scholarship and national recognition still

expected

Faculty development Teaching skills Technology Educational community Scholarship

Other forms of recognition…

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)

Point scale for each activity 0-25. Faculty fill in number of times – multiplied by points to give weighted score

Awards/dinner given for outstanding contributions

Still left with the problem of

TIME AND MONEY

Teaching Academies

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?

Undergraduate State appropriation Tuition Grants and contracts PRACTICE PLANS

GME Federal: CMS

Direct Indirect

State (in Virginia, only for Family Medicine)

Tracking Teaching Effort:Why Develop a Metric?

Six broad rationales:Mallon and Jones. Acad Med 2002;77:115-123

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?

Mallon and Jones (Acad Med 2002;77:115-123)

41 schools surveyed for teaching metrics Two main methods identified: contact hours and

RVUs Contact hours:

Some models allocated an additional amount of time to account for preparation and evaluation

Some models counted actual contact hours only RVU method

Assigned each teaching activity a relative weight

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.

Procedures categorized by CPT code Each code assigned a Relative Value, expressed as RVUs Relative Value Units can be used to track clinical

productivity

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

Challenges: 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

Yeh and Cahill 1999: Designed 3 step process for calculating teaching productivity based on RVUs:

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.

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

1999- Watson and Romrell (U. Fla.) reported development of a process that came to be known as “mission-based budgeting”.

3-step process 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

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

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

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 time-based metric.metric.

Stites et al. Acad Med 2005

Educational value unit (EVU) was defined as a unit of time spent in education of students and residents.

Avoided subjective assignment of relative values.

Chose to value different activities with the same metric regardless of subspecialty or level of experience.

0.1 EVU represented ~4 hrs work per week. Dollar value calculated for each 0.1 EVU.

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

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

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

Hospitalist with 4.5 months inpatient rounding and 2.5 months general medicine consults; also serves as student clerkship director: Clinical EVU

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 Core EVU

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

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

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

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.

The value of the EVU depends on university funding which can vary from year to year.

Limitation: no incentive program to measure quality of teaching effort and adjust compensation accordingly.

How are we measuring (valuing) educational effort at VCUHS?

References

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%20104-educational%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