SMD Update 2009: Looking back and looking forward.
Part 2 – Clinical affairs and education

Dr. David Guzick, M.D., Ph.D.

January 21, 2009

Here are the remaining entries from the Senior Associate Deans for Clinical Affairs, Graduate Education, Graduate Medical Education, and Medical Student Education.

Clinical Affairs (URMFG)—Richard I. Fisher, M.D.

Richard I. Fisher, M.D.

Looking back

General: As of July 1, 2008, I assumed the role of Vice President, University of Rochester Medical Center, Senior Associate Dean for Clinical Affairs, School of Medicine and Dentistry, and Director, University of Rochester Medical Faculty Group. My personal thanks to Ken DeHaven who led the group so successfully and helped make the transition much easier, as well as Martin Haibach and his staff who have assisted me in every possible way.

After individual meetings with each of the Chairs, we began to plan our new strategic initiatives for URMFG. In fact, we successfully modified and passed a revised Compensation Plan for Employed Clinical Faculty of URSMD. None of us fully anticipated the extent of financial problems that would challenge our country, state, hospital, school, and practice plan. As you are aware we are currently working our way through those challenges. However, let me reassure you regarding the fiscal health of URMFG. As shown in the paragraphs below, revenue is at an all time high and the organization is functioning smoothly. We are all dedicated to continuing to optimize revenue and increase efficiency so that we can attract and retain the best faculty to serve the needs of our patients, staff, and school.

Contract Management: In 2007 we set reimbursement targets for URMFG based upon a commissioned survey of peer academic health centers which showed reimbursement at the 75th percentile to be approximately 153% of then current Medicare. Dr. Berk set a goal to achieve this target in steps from 2008 to completion by 2010. URMFG has successfully negotiated contracts with Excellus and Aetna such that we are in line with reaching this goal. URMFG was also able to negotiate additional “endangered specialty” enhanced conversion factors to assist those divisions to recruit and retain sub-specialists. The 153% target is not a static figure and is expected to move with inflation. URMFG and Excellus have agreed to commission a second survey in 2009 to establish an updated reimbursement benchmark. Goals will be modified based on results of the new study.

Finance and Administration: URMFG was successful again in passing the FY 2008 financial audit by PricewaterhouseCoopers with no current year management comments. This confirms that all departments are completing cash reconciliations and following URMFG policies and procedures. This also attests that management is testing and auditing financial processes across all departments and is centrally following all accounting standards. URMFG ended the 2008 fiscal year with a positive change in net assets of $1.6 million.

Medical Faculty Group Business Office: The Medical Faculty Group Business Office continues to support departments to promote efficient operations:

Centralization of payment posting/document imaging for 10 departments. This service transfers the data entry functions from the departments to the Business Office, providing additional opportunity at the department level to increase to insurance follow up activities.
Provision of billing office assistance to the following departments: Medicine, Otolaryngology and Radiology. Services include interim billing manager support, insurance billing and/or follow up, charge entry and accounts receivable assessment/clean up.
Provision of Medicaid accounts receivable support (accounts aged greater than 180 days) for three departments, resulting in approximately $175K of additional revenue in CY 2008.
Flowcast implementations at numerous sites, including Cardiology-Brockport/Lakeside, Batavia Dermatology, Strong Geriatrics.

Medical Faculty Group Physician Services Office: The orientation program added a very successful half day computer training session to help providers learn the basics of all electronic programs that will be used in their practices. Examples are Allscripts, CIS, Flow Cast, Portal and other systems used by clinicians on a daily basis. Providers rate this program very high since they can become more efficient in their clinical work. The content of the Orientation Program and the new computer training has been approved for CME credit due to the quality and consistency of the content. CME credits will be issued beginning in 2009 and expected to be in the area of 10 credits. CME credits are required to be on the Medical Staff so this is an excellent way to help new providers get started.

The Access Project is being ramped up to help patients and referring doctors book appointments with ease to make our System the Gold Standard.

URMC Medical Staff Office: The URMFG credentialing service is NCQA certified for delegated contracts. In 2008 URMFG was audited by NCQA and earned a perfect score with no recommendations for improvement. Outstanding work by an excellent team.

New Joint Commission requirements were accomplished after many months of hard work. Focused Practice Review is new and required extensive work to accomplish a complete roll out throughout the system.

Looking forward

General:The commitment of URMFG to embrace Quality Improvement for outpatient in addition to inpatient services continues. The Quality Improvement Committee, chaired by Tom McInerny, MD, continues to work in collaboration with the SMH Quality program to improve patient safety and quality in URMFG faculty practices.

Contract Management: We will continue to negotiate to meet our three year target reimbursement level. Monitor contract performance to ensure enhanced rates are appropriately paid. Confirm with departments that "endangered" providers are being retained and recruitment slots are being filled. Implement processes to improve practice efficiencies, such as centralization of Medicare and Medicaid enrollment.

Finance and Administration: The URMFG Finance and Administration office will continue to work closely with University Audit to review all department billing offices to ensure appropriate controls and segregation of duties to mitigate and minimize fraud. The Finance office will work with departments to analyze costs and processes to evaluate opportunities for cost reduction and improved financial performance. The Allscripts Electronic Medical Record will continue to be rolled out.

Medical Faculty Group Business Office:

Complete centralization of payment posting by July 2009.
Develop centralized billing office model as a cost savings and efficiency option for URMFG departments.
Continued enhancement of business office services as business needs dictate.
Working jointly with SMH to evaluate potential to centralize common services (i.e., registration, patient call centers).

URMC Medical Staff Office: The Medical Staff Office will be fully paperless:

The Medical Staff Office will be a paperless credentialing service in 2009. Phase 1 is complete; the recredentialing process is paperless already. Phase II is a paperless initial credentialing process which will be fully implemented in January 2009. Files are imported and scanned so there is no paper at a significant cost advantage.
Phase III is electronic file review and is on target for full implementation first quarter 2009. URMC will be the first in the country with our vendor to by paperless. There is no paper coming in and therefore no paper to send for Chairmen to review. Chairman are notified and will have support as this unfolds and saves time and money.
A Lean Six Sigma team is implementing improvements to obtain documentation that causes delays in credentialing. The team is executing a data site, annual health and PPDs standardization, and synchronizing Infection Control Training with the recredentialing cycle to get started. These improvements and others will be executed throughout 2009.

Graduate Education—Edith Lord, Ph.D.

Edith Lord, Ph.D.

Looking Back

2008 was a year of change in the Office for Graduate Education. Dr. Paul LaCelle stepped down in July as Dean after ably guiding the graduate programs for 10 years. After a brief transition period, I began the process of learning the pleasures and challenges of being graduate dean. Fortunately, the staff remained intact and kept the daily functions operating smoothly. A short retreat held in late July brought together Graduate Education in the Biomedical Sciences (GEBS) program leaders, departmental chairs, center leaders and interested faculty, providing an opportunity to learn about the thirteen graduate programs and exchange ideas. Strengths and weaknesses were identified and discussed with an emphasis on maintaining and further improving the quality of our graduate students and the training experience we offer them. Several taskforces were assigned to address issues ranging from our current core courses to improving writing skills. The majority of these taskforces have finished their assignments, and we are beginning to implement their recommendations.

One of our larger incoming classes - 88 total Ph.D. students of which 77 are in the GEBS programs (including 5 MD/PhD students) - started their studies in the fall of 2008. This was well over the targeted 70 students due to a higher-than-expected percentage of accepted students who matriculated. This speaks well for the attractiveness of our graduate programs, but repetition of such a large class size would outstrip our capacity and budgeting. As part of the overall strategic plan, we had planned to increase the number of students accepted by 5 students each year over the next 5 years. Due to the large class in 2008 and the current budget restrictions, however, our target will again be 70 students for 2009. The recruiting season is just beginning with the number of applicants at this point very similar to last year.

Looking Forward

A major goal for the Office of Graduate Education and for each of our programs is to enhance the visibility and attractiveness of our websites. A web designer dedicated to the Offices of Graduate and Medical Education has been recruited and will begin work January 5, 2009. Our websites are the primary portals by which prospective students learn about graduate education at URMC and thus their appearance and user friendliness are of utmost importance. We are working with the University Information Technology Services to implement an online system to receive letters of recommendation and transcripts in connection with graduate student applications. This will greatly facilitate the application process. Many other aspects of graduate education including submission of grades, student progress reports and other forms are also now being done online to ease administrative burdens and provide instant information for students, faculty and graduate coordinators.

Increasing the diversity of our graduate classes is another major goal. One program that has been quite successful in aiding this effort is the PREP (Post-baccalaureate Research Education Program), originally started by Stephen Dewhurst, PhD and supported by NIH and the School of Medicine and Dentistry (SMD). A renewal of the NIH grant has been submitted and we are awaiting word on funding. The students trained in this program have had a high rate of success with 77% gaining admittance to PhD programs. Faculty and current graduate students are also attending meetings and visiting undergraduate universities to increase our recruitment of under represented minorities.

Another major goal for 2009 is to enhance the services and support provided to our over 200 postdoctoral fellows. A post-doctoral office is being established with a part-time faculty member to be appointed to deal with the numerous issues and concerns of this group, who are a vital component of the research programs at URMC.

Graduate Medical Education—Diane Hartmann, M.D.

Diane Hartmann, M.D.

Looking Back

For the academic year 2008 – 2009, Graduate Medical Education at the University of Rochester encompasses 672 trainees in 73 Accreditation Council on Graduate Medical Education (ACGME) training programs (25 residencies, 48 fellowships) as well as 7 dental residencies (54 trainees). The positive impact of these programs on the future medical workforce of Rochester is supported by data from 2008 graduates indicating that 72% of residents (64) and 17% of fellows (17) remained in the Rochester area.

Twenty-one of our programs were site-visited by the ACGME in 2008. Our high standard of excellence continues: 74.3% of our ACGME programs hold either a 5-year (42 programs) or 4-year (10 programs) accreditation cycle, as compared to a national average of 3.5 years.

The GME office partnered with hospital leadership this fall in a new initiative to conduct three system-wide required training sessions for all residents and fellows. The topics included (1) infection control/central line management, (2) quality outcome assessment and reporting practices, and (3) service excellence in communicating with patients and families. The intra-departmental sessions were well received by the trainees, and plans are in place to continue the series to highlight additional topics that are central to the medical center’s patient safety and quality of care initiatives.

Looking Forward

At the request of Congress and the Agency for Health Care Research and Quality (AHRQ), the Institute of Medicine (IOM) appointed “The Committee on Optimizing Graduate Medical Trainee Hours and Work Schedules to Improve Patient Safety.” This group held several meetings during 2008 to acquire information from a large and varied group of experts and stakeholders. Their final 350+ page report was published in December 2008 (http://www.iom.edu/?ID=60449) It includes a lengthy analysis of the projected $1.7 billion (0.4% of Medicare outlays) needed to finance the additional personnel needed to meet the report’s recommendations.

The specific recommendations are quite detailed, but a short description of how they are different from current New York State/ACGME work hour rules reveals:

Call shifts would be restricted to a maximum of 16 hours
Call is limited to maximum of every 3rd night (no averaging over the month).
The minimum time off after each day shift is 10 hours and night shift 12 hours.
Mandatory time off is 5 days per month, 1 day (24 hours) off per week (no averaging over the month) and one 48 hour period off per month.

The 80-hour work hour limit per week has not changed.

In response to the report, the ACGME recently sent an electronic survey to every program director and trainee in the country asking them to comment on the impact of the IOM recommendations regarding their potential value to resident education as well as the ease or difficulty in their implementation.

The IOM report and these stakeholder comments will be discussed at a special 2-day ACGME-sponsored conference in March 2009. The timeframe for potential new accreditation requirements has not been announced, but it is clear that 2009 will be filled with conversations regarding their potential positive and negative effects on resident education as well as implementation strategies within our programs.

Medical Student Education—David R. Lambert, M.D.

David R. Lambert, M.D.

Looking back

During 2008, we are proud of the many highlights and achievements that advanced medical student education. The Curriculum Steering Committee charged a task force to review critically the Double Helix Curriculum. The Task Force affirmed the strength and importance of the integration of clinical medicine and scientific knowledge throughout the four years, along with early clinical exposure. The Task Force recommendations included bringing clinical exposure from non-ambulatory/office areas earlier into the curriculum; design teams were formed to create such an experience. The new course, Skills in Complete Patient Evaluation (SCOPE) will begin in January 2010. The design process is ongoing and will result in a more balanced curriculum.

The School is continuing the process of identifying where the school’s Domains of Excellence (which mirror the ACGME Competencies) occur in the curriculum and strengthening those Domains that need greater presence. The Double Helix Curriculum Themes (Aging, Diversity, Health Systems, Nutrition, Prevention and Ethics and Law) are integral to a comprehensive medical education. Theme directors are working with individual course and clerkship directors to strengthen their presence throughout the curriculum.

The number of students with interest in the Academic Research Track continues to grow and this program has attracted the attention of other medical schools for its innovation. In the areas of technology, the school has decided to create its own computerized examination administration system, which will increase the flexibility of course directors to include images, graphics and video clips in examination questions. We believe this will improve our ability to assess different aspects of student knowledge and skills. Our students have continued their service to the community through many programs including U.R. Well (the student run health service for the uninsured), Saturday School (tutoring program for at-risk, inner-city elementary school students) and a program where medical students assist Rochester City School students in college applications. Our medical students continue to participate in a myriad of international experiences, learning, conducting research and providing clinical care.

The SMD hosted a meeting of admissions, curriculum and student services leaders from 12 other research intensive medical schools in May. This meeting allowed us to share some of our innovations and learn from other colleagues on ways to improve medical student education. The Class of 2008 had an excellent residency match with over 20% of the class staying at URMC for their residency. We have received many laudatory comments about the performance of our graduates from their residency program directors.

Looking Forward

Applicants to the medical school for entry in August of 2009 have remained stable while applications nationally are down slightly—testimony of the strength of our program. 2009 will see the school finalize the specifics of the fine tuning of the curriculum with further progress and finalization on the Domains of Excellence initiative. In response to student feedback and Task Force recommendations, the Surgery Clerkship will increase from 5 to 6 weeks beginning in July of 2009 in addition to two weeks of required sub-specialty surgery before graduation. In August of 2009, we will roll-out our new computerized examination system. We will also continue to look for ways to incorporate technology in teaching and hope to create interdisciplinary experiences for students. Advisory Deans and faculty will continue to provide students with excellent career counseling, assisting them in securing the best residency positions to meet their needs. We will also encourage students wishing to take a year out for research through the Academic Research Track and other prestigious, competitive funding opportunities.

I hope you agree that much progress was made in 2008, and that, despite current financial constraints, our prospects look bright for 2009.

Meliora,

David S. Guzick, MD, PhD
Dean, School of Medicine and Dentistry
University of Rochester