Monday, October 17, 2011

Does the University of Minnesota 

 Need an Academic Health Center?

Excerpts from a frank discussion, finally, at the Faculty Consultative Committee:

Faculty Consultative Committee
Thursday, October 6, 2011

3.    AHC Faculty Consultative Committee Response to the AHC Executive Steering Committee Report

    Professor Cramer now welcomed Professors Lytle, Oakes, and Weckwerth to the meeting and turned to Professor Campbell, chair of the AHC Faculty Consultative Committee (AHC FCC), to lead a discussion of the report from the AHC FCC.  The report follows, between the * * *.

* * *

On September 1, 2011, the Faculty Consultative Committee (FCC) charged the Academic Health Center (AHC) FCC with preparing a formal response to the draft report of the AHC Review Executive Steering Committee.  In terms of a formal response the AHC FCC was asked to address the following questions, as appropriate:

1.    What recommendations in the report does the committee endorse without change?

2.    What recommendations does the AHC FCC believe are ill advised?  What rationale led the AHC FCC to a conclusion different from that of the review committee?

3.    What recommendations would benefit from specific modifications; what are those modifications, and what motivated the committee’s thinking in suggesting any changes?

4.    What issues are not addressed in the report that the AHC FCC deems sufficiently important to warrant additional scrutiny, either prior to finalization of the report or at some later stage?

Members of AHC FCC are Colin Campbell, chair, Susan Berry, Cynthia Gross, Leslie Lytle, Paul Olin, Ned Patterson, and Cheryl Robertson.

Background:  Earlier this year, President Bruininks and Provost Sullivan charged an Executive Steering Committee with conducting a comprehensive review of the AHC.  The purpose of the review was to examine and define the appropriate role, mission, and value of the AHC and to make recommendations on how the AHC should be best organized in order to ensure that academic programs are properly supported, that there is no duplication of administrative services, and to make certain that interdisciplinary centers are appropriately aligned.

On September 7th and 16th, 2011, the AHC FCC met and discussed at-length the draft report of the AHC Review Executive Steering Committee.  Additionally, as suggested by the FCC, AHC FCC members made every effort to solicit opinions from a broad cross-section of AHC faculty, including school governance groups.  Based on those discussions and input received, the AHC FCC identified the following:

•    There was widespread agreement with the Executive Steering Committee’s Recommendation 1 that the AHC should continue to serve as the convening academic and administrative unit for the schools of Dentistry, Medicine, Nursing, Pharmacy, Public Health, and Veterinary Medicine.

•    There was general agreement with Recommendation 2, the AHC should report to a Vice President for Health Sciences reporting to the President, and that the Vice President should focus on interdisciplinary education, research and clinical programs.  However, the report lacks specificity regarding these domains, and did not propose a vision to direct defining its boundaries.

•    The response to Recommendation 3 was mixed.  With the exception of the Medical School, there was agreement that the Medical School Dean should report to the Provost on broad academic issues and not directly to the President.  As noted above, the interface between academics and clinical education and research has not been defined.

•    The AHC FCC found widespread support for Recommendation 4, to split the position of Vice President for Health Sciences and Dean of the Medical School into distinct and separate positions.  More outside-the-box thought should be given to looking at how to handle these positions such as the Medical School FAC’s suggestion to have the Medical School Dean also serve as the Vice President for Medical Services (VPMS), and have a separate Vice President for Health Sciences (VPHS) position focusing on interdisciplinary, interprofessional and intercollegiate programs that cut across the AHC colleges and other University collegiate units engaged in health science education and research.  [See attached letter from the Medical School Faculty Advisory Council (FAC)].

•    Recommendation 5 was generally viewed as acceptable.

•    Recommendation 6 was generally viewed as desirable.

•    The AHC FCC found widespread skepticism and unmet expectations regarding Recommendations 7 and 8.  The report did not go far enough in sharpening the focus or in leveraging enterprise resources.  The report calls for continuation of centers that are “essential and unique” and services/functions that are “critical and unique” to the AHC, but supports the status quo without delineating a framework for distinguishing what is essential, critical and unique.

•    The Executive Steering Group’s charge called for broad representation from AHC staff, faculty and University leaders on each of the sub-teams to ensure that there is a breadth of expertise represented.  However, despite requests by both the AHC FCC and the FCC, there was inadequate non-administrative faculty representation on the sub-teams.  As a result, inadequate rank and file representation served to undermine the credibility of the report.

•    The Executive Steering Committee’s recommendations were unremarkable.  The report lacked vision and failed to put forward a plan to make the AHC better.
•    The report was vague, ambiguous and lacked transparency.  For example, it lacked financial data to support its recommendations.  In addition to finances, the report did not fully address accountability, oversight or governance matters.

With regard to the FCC’s request to identify recommendations that are ill-advised or should be modified, it must be acknowledged that there was near-unanimous support for a focused AHC (Recommendations 1, 2 and 5) and separating the Dean of the Medical School from the AHC Vice President for Health Sciences (Recommendation 4).  Recommendations 3 and 4 needed greater specificity of scope and rationale to guide implementation.  With regard to Recommendations 7 and 8, the AHC FCC would like an independent body, including representation of faculty from all AHC colleges and external experts, to re-evaluate the findings and recommendations of the sub-teams given a significant number of their recommendations were overturned by the Executive Steering Committee without compelling rationale and supporting data.  As previously noted, the credibility of the report was undermined by the narrow composition of the Executive Steering Committee.  This re-review should begin by establishing a framework for assessing what is unique, critical and essential in order to optimally leverage enterprise-wide resources with the flexibility to meet unit-specific unique needs.

What was not addressed in the report?  The report was Twin Cities-focused, and did not consider the coordinate campuses, although at least three AHC schools have major divisions at Duluth and Rochester.  Finances and the size of the infrastructure of the AHC were not adequately addressed.  Data on the size, organization and functions of the AHC, separate from its colleges and centers, was omitted as well.

In conclusion, the AHC FCC as a group, and, on behalf of the collective faculty, there were significant concerns about the report Most notably, we question the degree to which representation of the faculty was achieved.  We also felt that the report lacked details that would address accountability, oversight, and governance.  The response to our solicitation of comments also reflected the divide between the Medical School and the other AHC schools about the role of the Medical School Dean.  The AHC FCC agrees that the AHC should continue to serve the health science schools, and the Vice President for Health Sciences should be a separate position from the Dean of the Medical School.  The report did not delve deep enough.  There needs to be a more in-depth analysis of the current AHC structure and finances evaluated by an independent committee that includes direct input from more rank and file AHC faculty and staff.  This report provided recommendations that were broad, non-specific and open to interpretation, and presented the status quo as acceptable while failing to present data to support that conclusion.  We would like to see a report that puts forth a vision for how the AHC can best serve the University community in years to come.

* * *

    Professor Campbell said that there was broad consensus on the AHC FCC on many of the items in the report, including that the AHC should exist, at least in its ideal form, that there should be a vice president for the AHC, and that the positions of Dean of the Medical School and vice president should be split.  The AHC FCC also found much of the report too vague. 

Except for those individuals from the Medical School, the AHC FCC did not believe the Dean of the Medical School should report to the President, but should report to the Provost.  The AHC FCC viewed skeptically the Executive Steering Committee report intimation that everything is working fine and there are no redundancies; there were few references to support the claim.  To many, the report represented an opportunity to sketch out a vision for the AHC, but it did not do so. 

There is also a concern that the report will not have as much impact as it might have because there were so few (one) faculty members involved.  They are also concerned, Professor Campbell concluded, that many faculty members in the AHC will not respond to the report, which should not be interpreted to mean that they are happy with the way things are, but rather reflects a perception that their opinions will have no impact on the process, which is regarded as a fait accompli.

    Professor Cramer said he has noticed that the College of Liberal Arts, the College of Science and Engineering, and the College of Education and Human Development all have large numbers of undergraduates; perhaps they should be grouped as Colleges with Large Undergraduate Majors and Programs, or CLUMP, and CLUMP should be provided its own administrative structure to provide and coordinate services.  The implementation of the CLUMP structure might be revenue-neutral from a University perspective, or then again it might not be--certainly staff in CLUMP colleges would probably appreciate having their own support structure, but, as matters stand they don't have that (instead they use central University services, e.g., room scheduling).  Does there really need to be a wrapper around the six colleges called the AHC?  Professor Campbell said that he could not respond effectively because he is not a clinician, and it is clinical activity that binds the AHC together.  Professor Cramer said that there is no CLUMP office of student services, instead there is a University-wide office, even though it serves primarily CLUMP colleges; why cannot there be an office of clinical care that serves the entire University?  It was noted that some AHC colleges have negligible clinical activity and some non-AHC units have substantial clinical activity, making the clinical activity justification seem weak.
     Professor Bitterman said that two points should be clarified with regard to any perceived discrepancies between the Medical School faculty view and the rest of the AHC colleges and schools. First, the Medical School Faculty Advisory Committee opinion (letter sent to the AHC FCC to be included in today's report to the FCC) is in close accord with the views expressed by the other AHC colleges, that deans should not become middle managers reporting to a vice president when, in the view of the faculty, they should be disciplinary leaders and run their colleges.  Second, to address the unique challenges posed by the position of UMP in the University reporting structure, the Medical School FAC suggests a very different type of combined Dean-VP position than the one discussed in the AHC Executive Steering Committee Report.   Their suggestion is that the Dean of the Medical School also be the Vice President for Medical Services.  In that capacity, the Dean-Vice President for Medical Services would report to the President only for matters related to the practice of medicine by UMP.  This is a nearly-$1-billion-dollar-per-year activity that includes complex contractual relationships with private health care corporations, creating a significant risk that it could stray from the core University academic mission without direct input and guidance from the President.  For all functions other than the practice of medicine, the Dean of the Medical School would be on par with all other deans and report to the Provost. This would focus the Dean of the Medical School only on the Medical School and practice plan, and not on the functions of any other college.

    Professor Pacala said that his concern is that there are already enough problems because the Medical School and UMP are run separately; if a separate reporting structure is created, that would further complicate coordination and synergy of the clinical mission of UMP and the academic mission of the Medical School.

    What has not come up, Professor Ziegler said, is the responsibility the AHC has for interprofessional education between the AHC schools.  He said he does not know how far that has progressed, but it was to be explored and is a reason to retain the AHC.  Professor Cramer observed that there are many intercollegiate programs at the University that do not have a special wrapper like the AHC.  But they are problematic to set up with clinical settings, Professor Ziegler said, and the AHC umbrella makes it easier to do so—especially if the program will be out in the state.

    Professor Luepker said the report:  (1) appears to be heavily driven by the word "clinical," but there are many people at the University who deliver clinical services but are not part of the AHC; and (2) of the AHC schools that are pulled together under that umbrella, his offers no clinical services and the paid clinical activity in Nursing and Pharmacy is trivial, the Committee just learned from Ms. Nunnally, so is the AHC limited to six schools, three of which do not have a clinical practice?  With respect to who reports to whom, Professor Luepker said, deans report to the Provost, but for clinical activities they report to the Vice President for the AHC.  If a college has no clinical activity, should it report only to the Provost?  There are universities with health science schools but without an AHC and the schools/departments take care of clinical imperatives.  He said he did not want the AHC to be driven only by clinical imperatives.

    Professor Ben-Ner asked about the linkages among clinical activities across Dentistry, Veterinary Medicine, Nursing, and so on; there are also schools that have professional degree programs that it was not found necessary to connect together for programmatic or financial reasons.  Professor Lytle said that in the School of Public Health, their interdisciplinary work often extends far beyond the AHC.  Administrative help from the AHC is not often required for the interdisciplinary work in which many faculty members in Public Health are involved.

    All of these comments, Professor Campbell said, are being made because there was no vision in the report; it was very pedestrian and contained nothing about what should be done.  It is a lost opportunity.  That is what he has heard over and over, Professor Bitterman agreed.
    One small counterweight, Professor Chomsky said, is that there has long been discussion about how interdisciplinary efforts do not work well all around the University; this report could have been an opportunity to improve that situation.  She said she did not know if the answer is to get rid of the AHC cluster. 

    Professor Chomsky asked about the AHC FCC report.  In the case of recommendation three, it appears to be the Medical School versus everyone else.  That division warrants more discussion.  If there is no body to engage in "visioning," and given the criticisms of the report about vagueness, lack of faculty participation, and lack of specificity, should one outgrowth of this discussion be a recommendation for involving more faculty members in the process? 

    Faculty apathy is not unique to the AHC, Professor Cramer said.  Speaking more to the point of shared identity, he noted that there were eight faculty members from AHC colleges present at this meeting; he asked them how they respond when asked by people in the supermarket what they do:  Do they say they are a professor in the AHC or a professor in, for example, the Medical School?  The AHC is supposed to be a brand that has value.  None of the eight said that they would identify themselves as being "in the AHC" as opposed to their college.
    Professor Pacala said he would identify himself as a professor in the Medical School.  There exists a curious disconnect here:  He recently attended a national conference on interprofessional education and the University of Minnesota was the "rock star" in the room, seen as the furthest along in developing it.  Relatively speaking, the AHC is doing well; on an absolute scale, it is doing poorly.  The potential of the AHC in interprofessional education is not being realized and there are few programs run or sponsored by the AHC.

    And some faculty members are very rigid, Professor Weckwerth observed.  In some cases, Professor Pacala agreed, but he said he does some interprofessional education in spite of the AHC.  There was a local conference on how the AHC could promote interprofessional education; he said then that what is needed is a common calendar and decent room scheduling.  Neither has happened.  Instead, he must call colleagues in the School of Nursing and the School of Public Health to work out times when an interprofessional class might be offered.  They wanted a hard look in the mirror with this report and they didn't get one, Professor Pacala concluded.

    Professor Ben-Ner said that it's not possible to control the many units and departments of the University directly from the center, so there is a need for intermediate structures.  Colleges are one way to decentralize, but those may also be too many.  Structures like the AHC may be the answer, but it's not an obvious one (the University experimented with provostal areas for health, arts and sciences, and the professions in the 1990s).  He said he did not believe the re-visioning of the AHC should be from the inside; it should be done externally, from above.  It is very difficult to look beyond one's own horizon.  He said he had no view about how an AHC might be structured—perhaps initially there were synergies that may not be present now.  He suggested there could be opportunities for interprofessional and interdisciplinary synergies and cost savings from reconfiguration of the University collegiate structure and reorganization, something the current University administration is considering already.  Professor Cramer agreed that the report seemed inward-looking even though the Executive Steering Committee included two vice presidents from outside the AHC.  The report does not reflect the outside looking in, he agreed.

    Professor VandenBosch noted that Professor Pacala had commented that classroom scheduling does not work—but there is an AHC office of classroom management, as was discussed earlier in the consideration of AHC finances.  This raises questions of why AHC classrooms are not managed by the central Office of Classroom Management, and whether central scheduling might be more efficient.  As apparently the scheduling of AHC classrooms is not effective currently, she asked? Ask any professor, Professor Pacala responded. 

Professor VandenBosch said she would like to hear more about how AHC colleges related to the non-AHC colleges.  Not all clinical activities are in the AHC, she also observed, and AHC colleges interact with other colleges in research and teaching, as well.  She said she would like to hear about the charge and the committee’s activities from the faculty member who served on the Executive Steering Committee—Professor Oakes.

    Professor Oakes reported that the gist of the charge to the Executive Steering Committee was to provide the new president with a richer understanding of the AHC and how it is integrated, or not, with the rest of the University.  The group met many times, and like all committees, it aimed for a horse and got a camel; committee work is about compromise and, for better or worse, the products of committees are typically compromised products.
 Regardless, those who drafted the report view this comment period as absolutely critical.  Dr. Oakes applauded the AHC FCC for having done its job and he believed that this Committee (the FCC) is correct to consider the report at its own level.  From his perspective, as an AHC professor and former member of this Committee, the elephant in the room is the question, "to what extent does the AHC help the University versus the University helping the AHC?"  Are they going together or apart?  What the President needs is an understanding of what the vision of the AHC is and whether or not it fits with the University.  Professor Luepker tapped a nerve:  When people say "clinical," non-clinical people shudder because lives are at stake, but that should not be used to dissuade serious reconsideration of the AHC structure. 
    The big issue on the campus, Professor Oakes continued, is the Washington Avenue moat, that physical and metaphorical divide that seems to create two universities from one.  There appears to be a lot of lost collaborative opportunity created by the current structures of the AHC.  Professor Oakes wondered how the moat could be drained and increased efficiencies exploited.

    Those comments are not in the report, Professor Bitterman observed, and if they had been, the report would have been better received.  How to make the University better is nowhere in the report nor are his insights, Professor Bitterman told Professor Oakes.  This was an opportunity to get talent together to make the life and health sciences at the University better for its students and faculty, and he objected to the absence of vision, creativity, innovation, and information.  This represents a missed opportunity.  The final AHC Executive Steering Committee Report as written would be unscored in an NIH study section—or "not recommended for further consideration, streamlined."
    It was a committee of people who did their best, Professor Oakes said, and he expressed the hope that the Committee would pursue vigorously the topics FCC has raised.  That is why the comment period is so important.

 What are the obstacles to addressing Professor Bitterman's points, Professor VandenBosch asked?  It is difficult for any group to look at itself, Professor Oakes said.  A self-report is important, but an external review is also always needed; there needs to be external peer review.  Professor Cramer is correct, Professor Oakes said:  Among others, there were vice presidents with a University perspective on the Executive Steering Committee.  And the group also included some very smart people who worked very hard to take a fresh look at things.  But the basic challenge is that self-assessment is hard to do. An outside assessment is typically needed, he emphasized.

    Professor Bearinger said she agreed with Professors Bitterman and Luepker.  She is in three of the six schools and would not identify herself as a professor in the AHC, but rather name the three schools.  When Senior Vice President Cerra had an AHC-level meeting to announce that the positions of dean and vice president would be joined, it was talked about as a temporary arrangement.  At the meeting, one person asked if any other dean could be the vice president; Dr. Cerra's answer was that any dean who could handle the clinical enterprise could take the position.  That told the story, she said.  When one looks at the dollars, clinical practice is a Medical School issue—and the tail should not be wagging the dog.  When she looks at the list of services provided by the AHC (reviewed earlier in the meeting), where they are going is disproportional to the pie chart entries (alos provided earlier in the meeting) with the vast majority servicing the Medical School.  If the services provided to the Medical School by the AHC were moved under the Medical School umbrella, what would remain?  If there is to be an AHC, one should ask what should be remain in the AHC and what could/should be provided by central administration.

    Professors Bitterman and Oakes addressed a more philosophical point about the AHC, Professor Cramer said, while Professor Bearinger spoke to a more technical point about the AHC budget.  He said he believes the services of AHC do need to be offered, and that if there are savings to be achieved, it is likely at the level of supervision, not of frontline workers.  Professor Bitterman agreed; "we need doers and the financial question is about the number of watchers."  

    Professor Bearinger said she has been involved in interdisciplinary education for the past two decades and, relative to the support she has received has come from Vice President Mulcahy and from the Graduate School, the AHC provided very little. 

    Professor Luepker said there are a couple of elephants in the room.
  One is the lack of vision on how to make the AHC better; on that point, there is nothing there.  He also had an "aha" moment during the discussion with Vice President Friedman and Ms. Nunnally earlier in the meeting:  Why was the AHC bureaucracy built?  Not for his school.  It is for the $200 million in centers it oversees.  There is an infrastructure there, with good people in it, but it is protecting itself.  Professor Oakes said he chaired the subcommittee on centers; by and large, the centers found little benefit to the AHC umbrella per se. But Ms. Nunnally said that is why the AHC is needed, Professor Luepker recalled—but the Cancer Center has its own human resources, public relations, and information technology staff.  Professor Oakes said he interviewed every center director and, if he recalled correctly, only one indicated they could not move from the AHC to the university level.
    When the AHC was created, Professor Weckwerth recalled, the issue was the hospital.  Its time is now past.  And the AHC could lose its shirt if it were linked to the hospital again.

    Professor Ziegler noted that the Medical School has an accreditation review in March and that in a mock review, it was said that the relationship between the dean and vice president needs to be clarified.

    Professor Chomsky said there is an odd disjuncture between the conversation at this meeting and the first bullet point in the AHC FCC report about a consensus view that the AHC should continue.  Professor Campbell said that those on the AHC FCC have asked what the AHC aspired to do and how much it would cost. The broad perception is that it costs too much and does too little.

Professor Cramer said that he thinks it is critically important that FCC communicate to the President its thoughts on the AHC report, but that rather than simply sending a memo, it would be good to learn from the President what he might find most useful in terms of formal or informal input
. He suggested that he and Professor Jacobs would talk with President Kaler about the report and ask what he would like to see from this Committee.

    Professor Cramer thanked Professors Lytle, Oakes, and Weckwerth for joining the meeting and adjourned it at 2:10.

A good start would be for the president to read this discussion.

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