Faculty Value: How do we measure it?

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Faculty ValueHow do we measure it?

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

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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 200479729-36

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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
  200479258-264
• 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 200075899-905

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• 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 insalary.

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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

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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

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What are ways in which teaching faculty might be
valued?

• Teaching as an avenue for career advancement??
  (personal)
• Linking teaching and ?? (departmental/personal)

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• 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 200479258-264

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• Promotion and tenure
• 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 2007411002-9

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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
  2007411002-9

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• Single-track vs. two (or more)-track systems
• Problems
• Elitism
• Expectations may constrain initiative
• Scholarship and national recognition still
  expected

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• Faculty development
• Teaching skills
• Technology
• Educational community
• Scholarship

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Other forms of recognition

• Schindler et al Recognizing clinical facultys
  contributions in education. Acad Med 2002
  77940-1
• 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

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• Still left with the problem of
• TIME AND MONEY

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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.

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Educational DollarsWhere 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)

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Tracking Teaching EffortWhy Develop a Metric?

• Six broad rationales
• Mallon and Jones. Acad Med 200277115-123
• Develop rational method for distributing funds to
  departments
• Track resources spent on teaching/educational
  activities
• Address department chairs mistrust of deans
  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

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How do medical schools use measurement systems to
track faculty activity and productivity in
teaching?

• Mallon and Jones (Acad Med 200277115-123)
• 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

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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.
• 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
  199914617-621

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• 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
  200277115-123

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• 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.

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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
  200277115-123

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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
• identifying revenue streams to fund each of the
  institutions missions
• evaluate each faculty members productivity with
  regard to each mission
• align funding source with faculty effort.
• Stites S et al. Acad Med
  2005801100-1106

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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
• listing all faculty educational activities,
• assigning each activity a weight in RVUs
• 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.

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Educational Value Units (EVUs)Stites S,
Vansaghi L, Pingleton S et al. Aligning
compensation with education. Acad Med
2005801100-1106

• 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 metric.

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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.

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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.

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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.

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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

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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 departments educational and
  clinical missions.

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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 MM 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
  internists teaching time, which is not
  specialty-specific.

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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.

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

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References

• Barchi RL, Lowery BJ. Scholarship in the medical
  faculty from the university perspective
  retaining academic values. Acad Med
  200075899-905
• Irby DM, Cooke M, Lowenstein D, Richards B. The
  Academy Movement A structural approach to
  reinvigorating the educational mission. Acad Med
  200479729-736.
• Mallon WT, Jones RF. How do medical schools use
  measurement systems to track faculty activity and
  productivity in teaching? Acad Med
  200277115-123
• Martin GJ et al. EVUs Development and
  implementation at two different institutions.
  www.im.org/.../Documents/AIM20Presentations/wkshp
  20104-educational20value20units.pdf
• Schindler et al. Recognizing clinical facultys
  contributions in education. Acad Med 2002
  77940-1
• Simpson D, Fincher RM, Hafler JP et al. Advancing
  educators and education by defining the
  components and evidence associated with
  educational scholarship. Med Educ 2007411002-9
• Stites S, Vansaghi L, Pingleton S et al. Aligning
  compensation with education. Acad Med
  2005801100-1106
• 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 200479258-264
• Yeh MM, Cahill DF. Quantifying physician teaching
  productivity using clinical relative value units.
  J Gen Intern Med 199914617-621