GHSU 8-Year Vision Appendices by Augusta University

Georgia Health Sciences University The Next Great American Academic Health Center

August 2011

APPENDICES

Appendices Appendix 1: Medical Education Investment Case Studies Appendix 2: Interprofessional Education Literature Appendix 3: Executive Summary: Burruss Institute Analysis Appendix 4: GHSU and MUSC: A Study of Nearly Identical Twins Appendix 5: Current and Future Clinical Delivery Platforms Appendix 6: Tertiary/Quaternary Outmigration by Service Line Appendix 7: Impact by Segment for Inpatients Appendix 8: Strategic Partnerships and Affiliation Tools Appendix 9: Cancer Center Position Paper Appendix 10: What the CSRA Will Look Like in 2020 Appendix 11: GHSU Sources of Funding Appendix 12: Closing the $100M Gap Appendix 13: Initiatives Driving Financial “Turnaround” Appendix 14: Tripp Umbach Report Appendix 15: Overview of the Environment Appendix 16: Creating a Biotech Park Appendix 17: AACI States’ Investment in Cancer Research Appendix 18: Physicians Practicing in Rural Locations

Appendix 1: Medical Education Investment Case Studies

Medical Education Investment Case Study

Alabama The state of Alabama operates two universities offering educational programs in the health sciences. Both universities are comprehensive research institutions and enroll fewer than 20,000 students annually. The University of Alabama, Birmingham (UAB) houses a School of Medicine that was founded in 1859. The University of South Alabama’s (USA) College of Medicine was founded in 1977. Together, these universities supply health care providers to the state’s population of 4.7 million citizens. Both universities qualify as an academic health center (AHC) based on the Association of Academic Health Center’s definition as a university that “consists of an allopathic or osteopathic medical school, one or more other health profession schools or programs (such as allied health, dentistry, graduate studies, nursing, pharmacy, public health, veterinary medicine), and one or more owned or affiliated teaching hospitals or health systems.” Both universities operate an integrated hospital. However, UAB fills nearly 800 residency positions annually, and its practice plan is health system‐based. Alternatively, USA fills just over 200 residency slots and has a medical school‐based practice plan. Situated in the state capital of Birmingham, UAB’s medical program is more than twice the size of the Mobile‐based USA – 700 and 293, respectively. At nearly 2,400 compared to USA’s 1,169, UAB attracts more applicants to its entering medical class of 176; USA enrolled 74 new medical students in 2010. Both universities enroll around 50 biomedical students; however, UAB appoints significantly more postdoctoral fellows (186 compared to 25 at USA). Overall, clinical faculty comprise the greater portion compared to basic science faculty at both universities. UAB employs about 5 times more clinical faculty than USA, severely differentiating the universities’ ratios of clinical faculty to medical students. While at UAB, the clinical education ratio of faculty to students is 1.4, USA’s ratio is 0.6. The same pattern applies to biomedical education, where the UAB biomedical faculty is 242 percent larger than USA’s. Similarly, the faculty to student ratio for biomedical sciences is 5.3 at UAB and 1.2 at USA. UAB’s investment in a substantially larger faculty has enabled it not only to train nearly twice as many physicians as USA, but to leverage its human capital to achieve substantially greater federal research funding and better national rankings among medical schools. The Alabama legislature invests significantly more state dollars in the UAB medical program. In FY2010 UAB’s allocation for medical education was $75.2 million, compared to USA’s $28.6 million. This dichotomy is congruent with the universities’ overall funding portfolio for medical education. And the return of investment is significant. UAB generates considerably more revenue in NIH research (15 times more), gifts and endowments (10 times more), and hospital transfers (three times more). Among medical schools with NIH funded research, UAB ranks 25 among 134; USA ranks 106. US News and World Report ranks medical schools on two sets of indicators – research and primary care. UAB’s research rank falls at 30 among 92 programs, and its primary care ranking is at 10 among 97. USA was not ranked in either set. Based on the information described, the capacity of these medical schools to carry out their tripartite mission combine with their investment from the state of Alabama is correlated with the programs’ national standing. With more students, more faculty, and more state funding, UAB has positioned itself as a force among academic health centers. While a competent educator of the state’s physicians, USA has not advanced itself in the same regard over its 34 years in operation.

Alabama Institutional Characteristics

GHSU

UAB

South Alabama

Medical School Founded Location AAHC Member Ownership/Control Relation to Parent University Program Array

1828 Augusta, GA Yes Public Freestanding/State System Allied Health, Dentistry, Nursing, Grad Studies, Medicine No Medical‐School Based GHS Medical Center

1859 Birmingham, AL Yes Public Related/Distant Allied Health, Dentistry, Grad Studies, Nursing, Optometry, Public Health No Health‐System Based University of Alabama Hospital

1977 Mobile, AL Yes Public Related/Proximate Allied Health, Nursing, Pharmacy No Medical‐School Based University of South Alabama Medical Center South Alabama 67 164 231 293 0 54 25 1,169 74 63 227 4,708,708 South Alabama $7,768,378 9,946,341 10,142,717 28,602,929 2,045,693 28,552,064 7,102,843 145,797 sq. ft. South Alabama 106 Unranked Unranked

AAU Member Practice Plan Location Hospital Name

Headcounts 2010 GHSU UAB Full‐time Basic Science Faculty 74 229 Full‐time Clinical Faculty 482 981 Total Full‐time Medical Faculty 556 1,210 Medical Student Enrollment 770 700 Enrolled Masters Students 1 16 Enrolled Doctoral Students 126 27 Enrolled Postdoctoral Fellows 143 186 Applications 2142 2,381 Matriculants 230 176 MD Degrees Conferred 180 180 Medical Residents 419 784 State Population 9,829,211 4,708,708 Financials 2010 GHSU UAB Med School Total Tuition and Fees $17,772,200 $18,691,706 NIH Total Research Funding 44,785,445 192,549,933 NIH Medical School Funding 43,654,047 158,476,912 Med School Government and Parent Support 103,889,527 75,234,440 Revenues from Gifts/Endowments for Med School 9,007,131 38,662,211 Expenditures/Transfers from Hospital Fund to Med Sch 35,783,312 102,900,880 Other Revenues to Med School 4,942,156 39,148,036 Total Research Space 231,929 sq. ft. 843,007 sq. ft. Rankings GHSU UAB NIH Awards FY10 70 25 US News Medical School Research 2011 71 30 US News Medical School Primary Care 2011 63 10 Sources: Association of American Medical Colleges, FY2010; Integrated Postsecondary Education Data System FY09; National Institutes of Health Awards 2010; Accreditation Council of Graduate Medical Education (FY10); NSF Research Space Facilities (FY09), NIH Rankings – Blue Ridge Medical Research Institute, 2010; US News and World Report Medical School Rankings, 2011 Note: Unranked ‐ School did not supply enough Information to US News to calculate a ranking.

Medical Education Investment Case Study

Georgia The state of Georgia is home to four universities offering educational programs in the health sciences, one of them public. Georgia Health Sciences University (GHSU) is a free‐standing health sciences university founded in 1828. Two of the privates – Emory University and Morehouse University – are based in Atlanta. Emory began its School of Medicine in 1911. Like Morehouse, Mercer University opened its medical program in the latter half of the twentieth century. Only GHSU and Emory qualify as an academic health center (AHC) based on the Association of Academic Health Center’s definition as a university that “consists of an allopathic or osteopathic medical school, one or more other health profession schools or programs (such as allied health, dentistry, graduate studies, nursing, pharmacy, public health, veterinary medicine), and one or more owned or affiliated teaching hospitals or health systems.” Emory fills 2.5 times more residency slots than GHSU at its multiple affiliated hospitals. GHSU has the largest medical student body in the state, approaching 800. Emory’s MD program is the second largest with around 530 students; however, its biomedical degree‐seeking cohort is almost four times GHSU’s. Both medical schools have significantly larger student bodies overall compared to Morehouse and Mercer. Emory’s clinical faculty is mammoth compared to its state peers. With nearly 2,000 clinical faculty alone, its total medical school corps is nearly four times that of GHSU and around 10 times larger than Morehouse and Mercer. The ratio of medical school faculty to medical/biomedical students at Emory is 2.0; all other Georgia medical schools’ ratios hover around 0.5. As a public entity, the state of Georgia is a major source of revenue for GHSU, which received around $103.9 million from the state in 2010. Although the state provides its largest funding source, GHSU is also reliant on its NIH funding of $43.6 million and hospital transfers of $35.8 million. Emory’s medical college is most dependent on its NIH funding of more than $250 million and its hospital transfers of $188 million. Among medical schools with NIH funded research, Emory is ranked 16th among 134; GHSU ranks 70th, Morehouse 93rd, and Mercer 130th. US News and World Report ranks medical schools on two sets of indicators – research and primary care. Given Emory’s investment in research and biomedical education, it’s not surprising that it holds a research rank of 21st of 92 programs; GHSU ranks 71st on this set of indicators. Emory’s primary care rank is 33rd among 97 medical schools, and GHSU’s is 63. Notably, ETSU is ranked 16th in the primary care indicators, higher than Emory. All other rankings were not published. The information described indicates that national reputation correlates primarily with the university’s investment in biomedical research. Emory’s sizable investment in a substantially larger faculty has enabled it not only to train more than twice as many physicians (students and residents combined) and researchers as its Georgia peers, but to leverage its human capital to achieve substantially greater federal research funding and better national rankings among medical schools.

Georgia

Institutional Characteristics Medical School Founded Location AAHC Member Ownership/Control Relation to Parent University Program Array AAU Member Practice Plan Location Hospital Name Headcounts 2010 Full‐time Basic Science Faculty Full‐time Clinical Faculty Total Full‐time Medical Faculty Medical Student Enrollment Enrolled Masters Students Enrolled Doctoral Students Enrolled Postdoctoral Fellows Applications Matriculants MD Degrees Conferred Medical Residents State Population Financials 2010 Med School Total Tuition and Fees NIH Total Research Funding NIH Medical School Funding Med School Government and Parent Support Revenues from Gifts/Endowments for Med School Expenditures/Transfers from Hospital Fund to Med Sch Other Revenues to Med School Total Research Space Rankings NIH Awards FY10 US News Medical School Research 2011 US News Medical School Primary Care 2011

GHSU 1828 Augusta, GA Yes Public Freestanding/State System Allied Health, Dentistry, Nursing, Grad Studies, Medicine No Medical‐School Based GHS Medical Center GHSU 74 482 556 770 1 126 143 2142 230 180 419 9,829,211 GHSU $17,772,200 44,785,445 43,654,047 103,889,527 9,007,131 35,783,312 4,942,156 231,929 sq. ft. GHSU 70 71 63

Emory 1915 Atlanta, GA Yes Private Related/Proximate Allied Health, Nursing, Public Health Yes Other Emory University Hospital Midtown Emory 174 1,858 2,032 530 0 474 639 5,797 135 109 1,081 9,829,211 Emory $34,162,414 252,638,476 223,723,094 1,316,410 72,447,474 188,246,637 58,123,873 1,538,820 sq. ft. Emory 16 21 33

Morehouse 1975 Atlanta, GA Yes Private Freestanding Grad Studies, Public Health

Mercer 1982 Macon, GA No Private Related/Proximate Allied Health, Nursing, Pharmacy

No Health‐System Based No Integrated Hospital

No Medical‐School Based No Integrated Hospital

Morehouse 56 158 214 215 79 24 16 4,052 57 56 135 9,829,211 Morehouse $8,222,281 23,221,261 16,540,081 9,505,213 3,665,436 32,864,939 7,502,106 85,479 sq. ft. Morehouse 93 Rank not published 16

Mercer 35 156 191 312 78 0 0 844 101 63 0 9,829,211 Mercer $14,048,785 1,835,078 1,045,526 34,857,189 456,196 34,319,553 3,145,654 145,446 sq. ft. Mercer 130 Rank not published Rank not published

Sources: Association of American Medical Colleges, FY2010; Integrated Postsecondary Education Data System FY09; National Institutes of Health Awards 2010; Accreditation Council of Graduate Medical Education (FY10); NSF Research Space Facilities (FY09), NIH Rankings – Blue Ridge Medical Research Institute, 2010; US News and World Report Medical School Rankings, 2011 Note: Rank not published ‐ US News calculated a numerical rank but does not publish it.

Medical Education Investment Case Study

Kentucky The state of Kentucky operates two universities offering educational programs in the health sciences. Both universities are comprehensive research institutions and enroll more than 20,000 students annually. The University of Kentucky (UKY) houses a College of Medicine that was founded in 1960. The University of Louisville (UofL) School of Medicine was founded in 1833. Together, these universities supply health care providers to the state’s population of 4.3 million citizens. Both universities qualify as an academic health center (AHC) based on the Association of Academic Health Center’s definition as a university that “consists of an allopathic or osteopathic medical school, one or more other health profession schools or programs (such as allied health, dentistry, graduate studies, nursing, pharmacy, public health, veterinary medicine), and one or more owned or affiliated teaching hospitals or health systems.” Both universities operate an integrated hospital. UofL enrolls a larger medical student body, filling nearly 70 more slots per cohort. This difference is significant when the comparable size of both universities’ clinical faculty and residencies is considered. Though both medical programs employ around 600 clinical medicine faculty, UKY’s ratio of these faculty to medical students is 1.4, matched up to less than 1 faculty per student at UofL. When looking at biomedical students, UofL has the larger student body but employs less about one basic sciences faculty for every two students; UKY’s biomedical faculty to student ratio is about one to one. The Kentucky legislature invests about $13.5 million more state dollars in the UofL medical program than the UKY program. In FY2010 UAB’s allocation for medical education was $75.2 million, compared to USA’s $28.6 million. The principal sources of funding for UKY comes from the NIH and hospital expenditures/transfers, which generates around $170 million; these same sources result in about $62 million at UofL. Among medical schools with NIH funded research, UKY ranks 57th among 134; UofL ranks 74th. US News and World Report ranks medical schools on two sets of indicators – research and primary care. UAB’s research rank falls at 60th among 92 programs, and its primary care ranking is at 60th among 97. UofL holds a research rank of 75th, and is not ranked on the primary indicators. Based on the information described, the capacity of these medical schools to carry out their tripartite mission and their investments from the state of Kentucky is seemingly comparable. Despite receiving around the same state allocation, UKY’s strategy to focus more of its resources on growing a strong corps of research and clinical faculty has resulted in a more powerful return on the state’s investment.

Kentucky Institutional Characteristics Medical School Founded Location AAHC Member Ownership/Control Relation to Parent University Program Array

U of Kentucky 1960 Lexington, KY Yes Public Related/Proximate Allied Health, Dentistry, Nursing, Pharmacy, Public Health No Health‐System Based University of Kentucky Hospital U of Kentucky 203 603 806 439 25 195 134 1,999 113 94 543 4,339,367 U of Kentucky $17,770,869 83,428,930 65,904,424 34,558,042 17,517,517 103,879,490 18,998,598 2,086,712 sq. ft. Univ of Kentucky 57 60 55

U of Louisville 1833 Louisville, KY Yes Public Related/Proximate Dentistry, Nursing, Public Health, Grad Studies No Medical‐School Based U of L Health Care University Hospital U of Louisville 102 611 713 624 83 183 114 2,678 180 136 570 4,339,367 U of Louisville $20,813,451 47,148,140 37,447,985 48,158,446 25,004,963 25,004,963 4,449,111 462,827 sq. ft. Univ of Louisville 74 75 Rank not published

AAU Member Practice Plan Location Hospital Name Headcounts 2010 Full‐time Basic Science Faculty Full‐time Clinical Faculty Total Full‐time Medical Faculty Medical Student Enrollment Enrolled Masters Students Enrolled Doctoral Students Enrolled Postdoctoral Fellows Applications Matriculants MD Degrees Conferred Medical Residents State Population Financials 2010 Med School Total Tuition and Fees NIH Total Research Funding NIH Medical School Funding Med School Government and Parent Support Revenues from Gifts/Endowments for Med School Expenditures/Transfers from Hospital Fund to Med Sch Other Revenues to Med School Total Research Space Rankings NIH Awards FY10 US News Medical School Research 2011 US News Medical School Primary Care 2011 Sources: Association of American Medical Colleges, FY2010; Integrated Postsecondary Education Data System FY09; National Institutes of Health Awards 2010; Accreditation Council of Graduate Medical Education (FY10); NSF Research Space Facilities (FY09), NIH Rankings – Blue Ridge Medical Research Institute, 2010; US News and World Report Medical School Rankings, 2011 Note: Rank not published ‐ US News calculated a numerical rank but does not publish it

Medical Education Investment Case Study

Louisiana The Louisiana State University (LSU) system operates two public, free‐standing health sciences centers (HSC). Founded in 1931, LSU‐HSC New Orleans enrolls approximately 2,600 total students annually. LSU‐ HSC Shreveport, founded in 1969, enrolls fewer than 900 students overall each year. The state is also home to Tulane University, a private, comprehensive research university whose School of Medicine was founded in 1834. Collectively, these universities supply health care providers to the state’s population of 4.5 million citizens. All of these universities qualify as an academic health center (AHC) based on the Association of Academic Health Center’s definition as a university that “consists of an allopathic or osteopathic medical school, one or more other health profession schools or programs (such as allied health, dentistry, graduate studies, nursing, pharmacy, public health, veterinary medicine), and one or more owned or affiliated teaching hospitals or health systems.” New Orleans and Tulane enroll more than 250 more MD students each than Shreveport. New Orleans employs nearly 600 medical school faculty compared to Tulane’s 481 and Shreveport’s 370. New Orleans also holds the state’s most residency slots, exceeding 550; Tulane and Shreveport have approximately the same number of slots, both in the mid‐400s. In FY2010, the Louisiana legislature allocated approximately $46 million to each medical program. The two universities diverge only slightly when compared other funding sources. Although, Shreveport’s NIH funding is just half of New Orleans’ and a third of Tulane’s, all three universities are ranked in the bottom half of funded medical schools. None of these institutions are ranked by US News and World Report. The only significantly divergent indicators are hospital fund transfers (New Orleans’ tops $137 million) and research space (Tulane’s nears 500,000 square feet). Based on the information described, the capacity of these medical schools to carry out their tripartite missions is comparable when considering faculty and student capacity. Comparing the public centers, their investments from the state of Louisiana is nearly identical. No doubt, all of these universities are competent physician educators. However, none of these universities has positioned the state of Louisiana for distinction in the areas of clinical care and biomedical research.

Louisiana

Institutional Characteristics Medical School Founded Location AAHC Member Ownership/Control Relation to Parent University Program Array

AAU Member Practice Plan Location Hospital Name

GHSU 1828 Augusta, GA Yes Public Freestanding/State System Allied Health, Dentistry, Nursing, Grad Studies, Medicine No Medical‐School Based GHS Medical Center

LSU‐New Orleans 1931 New Orleans, LA Yes Public Freestanding/State System Allied Health, Dentistry, Grad Studies, Nursing, Public Health, Veterinary No Medical‐School Based Medical Center of Louisiana at New Orleans LSU‐New Orleans 96 474 570 747 1 0 0 1139 192 170 562 4,533,372 LSU‐New Orleans $10,581,561 28,163,540 27,353,278 46,056,344 1,382,567 137,653,408 2,350,292 192,357 sq. ft. LSU‐New Orleans 83 Unranked Unranked

LSU‐Shreveport 1969 Shreveport, LA Yes Public Freestanding/State System Allied Health, Grad Studies

Tulane 1834 New Orleans, LA Yes Private Related/Proximate Public Health

No Medical‐School Based LSU Health Shreveport

Yes Medical‐School Based Tulane University Hospital & Clinic Tulane 103 378 481 729 202 103 71 10,038 187 135 420 4,533,372 Tulane $38,428,935 45,866,180 21,750,763 $0 11,312,024 61,372,872 19,033,436 454,372 sq. ft. Tulane 81 Unranked Unranked

Headcounts 2010 GHSU LSU‐Shreveport Full‐time Basic Science Faculty 74 73 Full‐time Clinical Faculty 482 297 Total Full‐time Medical Faculty 556 370 Medical Student Enrollment 770 468 Enrolled Masters Students 1 2 Enrolled Doctoral Students 126 78 Enrolled Postdoctoral Fellows 143 76 Applications 2142 727 Matriculants 230 118 MD Degrees Conferred 180 110 Medical Residents 419 472 State Population 9,829,211 4,533,372 Financials 2010 GHSU LSU‐Shreveport Med School Total Tuition and Fees $17,772,200 $7,997,721 NIH Total Research Funding 44,785,445 13,887,941 NIH Medical School Funding 43,654,047 13,966,734 Med School Government and Parent Support 103,889,527 46,162,980 Revenues from Gifts/Endowments for Med School 9,007,131 2,046,048 Expenditures/Transfers from Hospital Fund to Med Sch 35,783,312 49,940,047 Other Revenues to Med School 4,942,156 3,037,995 Total Research Space 231,929 sq. ft. 93,805 sq. ft. Rankings GHSU LSU‐Shreveport NIH Awards FY10 70 98 US News Medical School Research 2011 71 Unranked US News Medical School Primary Care 2011 63 Unranked Sources: Association of American Medical Colleges, FY2010; Integrated Postsecondary Education Data System FY09; National Institutes of Health Awards 2010; Accreditation Council of Graduate Medical Education (FY10); NSF Research Space Facilities (FY09), NIH Rankings – Blue Ridge Medical Research Institute, 2010; US News and World Report Medical School Rankings, 2011 Note: Unranked ‐ School did not supply enough Information to US News to calculate a ranking.

Medical Education Investment Case Study

North Carolina The state of North Carolina is home to four universities offering educational programs in the health sciences. The University of North Carolina‐Chapel Hill (UNC) and East Carolina University (ECU) are public universities housing medical programs founded in 1879 and 1977, respectively. Duke University and Wake Forest University began training physicians in the early twentieth century. Collectively, these universities provide health care providers to North Carolina’s 9.5 million citizens. All of these medical schools qualify as an academic health center (AHC) based on the Association of Academic Health Center’s definition as a university that “consists of an allopathic or osteopathic medical school, one or more other health profession schools or programs (such as allied health, dentistry, graduate studies, nursing, pharmacy, public health, veterinary medicine), and one or more owned or affiliated teaching hospitals or health systems.” All manage integrated hospitals and have a substantial number of residency slots, with ECU holding the lowest at 332 and Duke the most at nearly 900. UNC has the largest medical student body in the state, exceeding 600. Duke and Wake Forest each enroll nearly 500, while ECU’s medical student body is just over 300. Duke’s and UNC’s enrollment of biomedical students are significant: more than 1,000 each, 75 percent doctoral candidates. Biomedical degree‐seekers account for around 300 students at Wake Forest, while fewer than 150 such students are enrolled at ECU. Undoubtedly, North Carolina’s medical schools make sizable investments in their faculty sizes. With the exception of ECU’s small faculty of 419, they all employ between 1,000 and 1,500 faculty, primarily clinical. Duke has the highest ratio of clinical faculty to medical students at 2.7. However, all of North Carolina’s other medical schools boast ratios of at least 1.1. At 0.7, Wake Forest has the highest ratio of basic sciences faculty to biomedical students; in this case, Duke and UNC are lowest at 0.2 and 0.3, respectively. As public entities, the state of North Carolina is a major source of revenue for UNC and ECU. In 2010, ECU received around $63 million from the state, its largest funding source. Although the $176 million allocated to UNC is significant, it actually received more funding from NIH ($238 million) and its hospital ($122 million). Duke is also most dependent on its NIH funding ($306 million) and hospital transfers ($151 million). Although Wake Forest’s combined $193 million in NIH and hospital funding is substantial, the medical school’s unknown revenues of $115 million accounts for the largest itemized portion. North Carolina boasts three schools among the 134 medical programs with NIH funded research: Duke ranks 8th, UNC 14th, and Wake Forest 44th; at 117th, ECU is the only not in the NIH top 50. US News and World Report ranks medical schools on two sets of indicators – research and primary care. Given their investment in research and biomedical education, it’s not surprising that the research ranks for Duke (4th), UNC (20th), and Wake Forest (44th) are also in the top 50 among 92 programs (ECU’s research rank was not published). Notably, Duke’s primary care rank is actually lowest among its state peers – 41st among 97 medical schools. UNC was ranked 2nd, ECU 10th, and Wake Forest 37th. The information described indicates that national reputation, indicated by rankings and AAU‐distinction, correlates primarily with the university’s investment in faculty and biomedical research. Home to three of the nation’s top medical programs, Duke’s, UNC’s, and Wake Forest’s sizable investments in substantially larger faculty have enabled them not only to train more than twice as many physicians (students and residents combined) and researchers as ECU, but to leverage their human capitals to achieve substantially greater federal research funding and better national rankings among medical schools.

North Carolina

Institutional Characteristics Medical School Founded Location AAHC Member Ownership/Control Relation to Parent University Program Array

AAU Member Practice Plan Location Hospital Name

GHSU 1828 Augusta, GA Yes Public Freestanding/State System Allied Health, Dentistry, Nursing, Grad Studies, Medicine No Medical‐School Based GHS Medical Center

Duke 1930 Durham, NC Yes Private Related/Proximate

East Carolina 1977 Greenville, NC Yes Public Related/Proximate

UNC‐Chapel Hill 1879 Chapel Hill, NC Yes Public Related/Proximate

Wake Forest 1902 Winston‐Salem, NC Yes Private Related/Proximate

Nursing

Allied Health, Dental, Nursing

Dentistry, Nursing, Pharmacy, Public Health

Allied Health, Grad Studies, Public Health

Yes Health‐System Based Duke University Hospital

No Medical‐School Based Pitt County Memorial Hospital East Carolina 86 333 419 306 80 62 14 918 78 65 332 9,535,483 East Carolina $3,045,337 8,684,762 6,119,479 62,955,222 3,627,658 46,808,456 2,973,105 220,245 sq. ft. East Carolina 117 Rank not published 10

Yes Health‐System Based University of North Carolina Hospitals UNC‐Chapel Hill 310 1,069 1,379 666 326 704 434 4,629 160 157 675 9,535,483 UNC‐Chapel Hill $14,284,682 323,042,975 238,601,335 176,428,809 18,412,071 122,034,558 45,936,265 1,662,923 sq. ft. UNC‐Chapel Hill 14 20 2

No Medical‐School Based North Carolina Baptist Hospital Wake Forest 223 795 1,018 481 41 261 173 7,389 120 106 627 9,535,483 Wake Forest $29,792,905 95,654,464 92,210,235 860,000 35,296,828 97,155,599 115,086,083 1,640,107 sq. ft. Wake Forest 44 45 37

Headcounts 2010 GHSU Duke Full‐time Basic Science Faculty 74 195 Full‐time Clinical Faculty 482 1,232 Total Full‐time Medical Faculty 556 1,427 Medical Student Enrollment 770 464 Enrolled Masters Students 1 305 Enrolled Doctoral Students 126 716 Enrolled Postdoctoral Fellows 143 468 Applications 2,142 4,832 Matriculants 230 100 MD Degrees Conferred 180 105 Medical Residents 419 876 State Population 9,829,211 9,535,483 Financials 2010 GHSU Duke Med School Total Tuition and Fees 17,772,200 $28,390,000 NIH Total Research Funding 44,785,445 336,836,463 NIH Medical School Funding 43,654,047 305,653,535 Med School Government and Parent Support 103,889,527 6,215,461 Revenues from Gifts/Endowments for Med School 9,007,131 83,758,859 Expenditures/Transfers from Hospital Fund to Med Sch 35,783,312 150,840,169 Other Revenues to Med School 4,942,156 54,022,636 Total Research Space 231,929 sq. ft. 1,190,356 sq. ft. Rankings GHSU Duke NIH Awards FY10 70 8 US News Medical School Research 2011 71 4 US News Medical School Primary Care 2011 63 41 Sources: Association of American Medical Colleges, FY2010; Integrated Postsecondary Education Data System FY09; National Institutes of Health Awards 2010; Accreditation Council of Graduate Medical Education (FY10); NSF Research Space Facilities (FY09), NIH Rankings – Blue Ridge Medical Research Institute, 2010; US News and World Report Medical School Rankings, 2011 Note: Rank not published ‐ US News calculated a numerical rank but does not publish it.

Medical Education Investment Case Study

South Carolina The state of South Carolina operates two universities offering educational programs in the health sciences. The University of South Carolina (USC) is a comprehensive, multi‐campus research university enrolling nearly 45,000 students; it houses a School of Medicine that was founded in 1977. The Medical University of South Carolina (MUSC) was founded in 1824 and is a free‐standing health sciences university enrolling around 2,500 total students. Together, these universities supply health care providers to the state’s population of 4.6 million citizens. Both universities qualify as an academic health center (AHC) based on the Association of Academic Health Center’s definition as a university that “consists of an allopathic or osteopathic medical school, one or more other health profession schools or programs (such as allied health, dentistry, graduate studies, nursing, pharmacy, public health, veterinary medicine), and one or more owned or affiliated teaching hospitals or health systems.” However, USC’s hospital affiliation is not integrated with the operations of the university as is the MUSC Medical Center. MUSC fills nearly 600 residency positions annually, whereas USC fills only two. Both universities have medical school‐based practice plans. Situated in the state capital of Columbia, USC’s medical program is about half the size of the Charleston‐ based MUSC – 329 and 648, respectively. MUSC enrolls 16 percent more biomedical students, but its primary focus on biomedical education is doctoral whereas USC’s enrollment is conversely master’s level. Overall, clinical faculty comprise the greater portion compared to basic science faculty at both universities. MUSC employs about 465 percent more clinical faculty than USC, severely differentiating the universities’ ratios of clinical faculty to medical students. While at MUSC, the clinical education ratio of faculty to students is 1.4, USC’s ratio is 0.5. The same pattern applies to biomedical education, where the MUSC biomedical faculty is 158 percent larger than USC’s. Similarly, the faculty to student ratio for biomedical sciences is 0.6 at MUSC and 0.3 at USC. MUSC’s investment in a substantially larger faculty has enabled it not only to train nearly twice as many physicians as USC, but to leverage its human capital to achieve substantially greater federal research funding and better national rankings among medical schools. The South Carolina legislature invests significantly more state dollars in the MUSC medical program. In FY2010 MUSC’s allocation for medical education was $53.7 million, compared to USC School of Medicine’s $19.7 million. This dichotomy is congruent with the universities’ overall funding portfolio for medical education. And the return on investment is significant. MUSC generates considerably more revenue in NIH research (813 percent more), gifts and endowments (188 percent more), and hospital transfers (127 percent more). Among medical schools with NIH funded research, MUSC ranks 47 among 134; USC ranks 107. US News and World Report ranks medical schools on two sets of indicators – research and primary care. For research, MUSC ranked 60 and USC ranked 91 out 92 programs. For primary care, of 97 medical schools, MUSC was ranked at 58 and USC at 73. Based on the information described, the capacity of these medical schools to carry out their tripartite mission combined with their investment from the state of South Carolina is correlated with the programs’ national standing. With more students, more faculty, more state funding, and an integrated teaching hospital, MUSC has positioned itself as a force among academic health centers. While a competent educator of the state’s physicians, USC has not advanced itself in the same regard over its 34 years in operation.

South Carolina Institutional Characteristics Medical School Founded Location AAHC Member Ownership/Control Relation to Parent University Program Array AAU Member Practice Plan Location Hospital Name

GHSU 1828 Augusta, GA Yes Public Freestanding/State System Allied Health, Dentistry, Nursing, Grad Studies, Medicine No Medical‐School Based GHS Medical Center

MUSC 1824 Charleston, SC Yes Public Freestanding/Health Sciences University Allied Health, Dentistry, Grad Studies, Nursing, Pharmacy No Medical‐School Based Medical University of South Carolina Medical Center MUSC 160 915 1,075 648 59 197 207 2,653 165 133 596 4,625,364 MUSC 19,995,760 93,078,267 90,451,074 53,708,975 19,860,765 76,075,341 7,700,491 574,062 sq. ft. MUSC 47 60 58

USC 1977 Columbia, SC Yes Public Related/Proximate Grad Studies, Health Administration, Nursing, Pharmacy, Public Health No Medical‐School Based No Integrated Hospital

Headcounts 2010 GHSU USC Full‐time Basic Science Faculty 74 62 Full‐time Clinical Faculty 482 162 Total Full‐time Medical Faculty 556 224 Medical Student Enrollment 770 329 Enrolled Masters Students 1 172 Enrolled Doctoral Students 126 48 Enrolled Postdoctoral Fellows 143 21 Applications 2142 2,647 Matriculants 230 90 MD Degrees Conferred 180 68 Medical Residents 419 2 State Population 9,829,211 4,625,364 Financials 2010 GHSU USC Med School Total Tuition and Fees $17,772,200 11,771,306 NIH Total Research Funding 44,785,445 31,289,279 NIH Medical School Funding 43,654,047 9,875,537 Med School Government and Parent Support 103,889,527 19,685,737 Revenues from Gifts/Endowments for Med School 9,007,131 6,905,170 Expenditures/Transfers from Hospital Fund to Med Sch 35,783,312 33,583,605 Other Revenues to Med School 4,942,156 866,625 Total Research Space 231,929 sq. ft. 569,491 sq. ft. Rankings GHSU USC NIH Awards FY10 70 107 US News Medical School Research 2011 71 91 US News Medical School Primary Care 2011 63 73 Sources: Association of American Medical Colleges, FY2010; Integrated Postsecondary Education Data System FY09; National Institutes of Health Awards 2010; Accreditation Council of Graduate Medical Education (FY10); NSF Research Space Facilities (FY09), NIH Rankings – Blue Ridge Medical Research Institute, 2010; US News and World Report Medical School Rankings, 2011 Note:Unranked ‐ School did not supply enough Information to US News to calculate a ranking.

Medical Education Investment Case Study

Tennessee The state of Tennessee is home to four universities offering educational programs in the health sciences, two of them public. The University of Tennessee Health Sciences Center (UTHSC) is a statewide academic health system based in Memphis; it houses a College of Medicine that was founded in 1911. East Tennessee State University (ETSU) is a comprehensive, research university located in Johnson City; its foray into medical education began in 1978. The two private medical schools – at Vanderbilt University and Meharry University – are based in Nashville and were founded in the mid‐1870s. Collectively, these universities provide health care providers to Tennessee’s 6.3 million citizens. All of these medical schools qualify as an academic health center (AHC) based on the Association of Academic Health Center’s definition as a university that “consists of an allopathic or osteopathic medical school, one or more other health profession schools or programs (such as allied health, dentistry, graduate studies, nursing, pharmacy, public health, veterinary medicine), and one or more owned or affiliated teaching hospitals or health systems.” However, only UTHSC and Vanderbilt operate integrated hospitals. They also each fill more than 800 residency positions annually, whereas ETHSU fills 266 and Meharry fills just 95. UTHSC has the largest medical student body in the state, exceeding 600. Meharry and Vanderbilt each enroll more than 400, while ETSU’s medical student body is less than 300. Vanderbilt’s enrollment of biomedical students is significant however: nearly 800. Biomedical degree‐seekers account for just under 150 students at UTHSC, while fewer than 100 such students are enrolled at Meharry and ETSU. For all of these universities, the vast majority of biomedical students are doctoral candidates. Vanderbilt and UTHSC have the highest faculty to student ratios. Vanderbilt’s employs 1.5 faculty for each medical and biomedical student; UTHSC employs just under one per student. Conversely, both Meharry and ETSU employ about one faculty per two students. As one of the nation’s top medical schools and a member of the distinguished Association of American Universities, Vanderbilt’s sizable investment in a substantially larger faculty has enabled it not only to train more than twice as many physicians and researchers as its Tennessee peers, but to leverage its human capital to achieve substantially greater federal research funding and better national rankings among medical schools. As public entities, the state of Tennessee is a major source of revenue for ETSU and UTHSC. In 2010, ETSU received around $36 million from the state, its largest funding source. Although the $48 million allocated to UTHSC is significant, it actually received more funding from its hospital (around $70 million). Compared to these public universities, the private Vanderbilt medical college is most dependent on its NIH funding of nearly $300 million. Among medical schools with NIH funded research, Vanderbilt is ranked 11th among 134; UTHSC ranks 78th, Meharry is 84th, and ETSU ranks 122nd. US News and World Report ranks medical schools on two sets of indicators – research and primary care. Given Vanderbilt’s investment in research and biomedical education, it’s not surprising that its research rank 15th of 92 programs, yet its primary care rank is 55th among 97 medical schools. UTHSC is ranked in the 70s in both groupings. Notably, ETSU is ranked 37th in the primary care indicators, higher than Vanderbilt. The information described indicates that national reputation, indicated by rankings and AAU‐distinction, correlates primarily with the university’s investment in biomedical research. The state of Tennessee, having divided its medical education investment among two public universities, has established to competent but insignificant education programs rather than poising one to serve as the state’s leader for cutting‐edge clinical care and biomedical research.

Tennessee

Institutional Characteristics Medical School Founded Location AAHC Member Ownership/Control Relation to Parent University Program Array

GHSU 1828 Augusta, GA Yes Public Freestanding/State System

East Tennessee State 1978 Johnson City, TN Yes Public Related/Proximate

Allied Health, Dentistry, Nursing, Grad Studies, Medicine No Medical‐School Based GHS Medical Center

Allied Health, Nursing, Public Health

Meharry Med College 1876 Nashville, TN Yes Private Freestanding/Health Sciences University Allied Health, Dentistry, Grad Studies

No Medical‐School Based No Integrated Hospital

GHSU 74 482 556 770 1 126 143 2142 230 180 419 9,829,211 GHSU 17,772,200 44,785,445 43,654,047 103,889,527 9,007,131 35,783,312 4,942,156 231,929 sq. ft. GHSU 70 71 63

East Tennessee State 44 170 214 254 3 25 7 1,616 71 62 266 6,346,105 East Tennessee State 7,150,919 3,614,538 3,300,167 35,989,185 856,648 20,512,896 308,065 155,524 sq. ft. East Tennessee State 122 Unranked 37

Meharry Med College 58 131 189 425 39 59 23 4,660 105 68 95 6,346,105 Meharry Med College 14,245,551 27,745,098 26,713,365 7,729,365 3,806,260 31,354,449 2,778,231 257,608 sq. ft. Meharry Med College 84 Unranked Unranked

Univ of Tenn Health SciCtr 1911 Memphis, TN Yes Public Related/Proximate

Vanderbilt 1874 Nashville, TN Yes Private Related/Proximate

Allied Health, Dentistry, Grad Studies, Nursing, Pharmacy, Veterinary No Medical‐School Based University of Tennessee Medical Center Univ of Tenn Health SciCtr 118 625 743 627 37 106 93 1,371 165 138 802 6,346,105 Univ of Tenn Health SciCtr 15,873,473 42,905,483 34,488,486 47,753,482 16,116,325 69,918,546 25,499,447 1,853,764 sq. ft. Univ of Tenn Health SciCtr 78 78 73

Nursing

Yes Medical‐School Based Vanderbilt University Medical Center Vanderbilt 389 1,624 2,013 452 143 634 493 5,397 105 103 813 6,346,105 Vanderbilt 32,430,179 304,539,723 296,277,355 $0 34,324,250 147,967,389 6,257,551 798,908 sq. ft. Vanderbilt 11 15 55

Sources: Association of American Medical Colleges, FY2010; Integrated Postsecondary Education Data System FY09; National Institutes of Health Awards 2010; Accreditation Council of Graduate Medical Education (FY10); NSF Research Space Facilities (FY09), NIH Rankings – Blue Ridge Medical Research Institute, 2010; US News and World Report Medical School Rankings, 2011 Note:Unranked ‐ School did not supply enough Information to US News to calculate a ranking.

Medical Education Investment Case Study

Graduate Medical Education A study of graduate medical education slots in the states of Alabama, Louisiana, South Carolina, and Georgia shows that most residencies, regardless of physical location, are associated with some academic health program. In all cases, at least half of the states’ residency slots are directly managed by a university. Of these states, Georgia is the most populous and holds the most GME positions overall. A total 16 locations house residents, 12 of those with at least one medical school affiliation. More than 75 percent are university‐based, and 99 percent are university‐affiliated. Nearly half of Georgia’s residencies are administered by Emory University School of Medicine. Georgia Health Sciences University operates about 20 percent of GME slots, and just under a third overall is affiliated with the state’s academic health center. Morehouse School of Medicine manages about six percent of the state’s slots and is affiliated with another three percent. Mercer is affiliated with 14 percent of statewide residencies but manages none. The practice of affiliating residencies with academic health centers is equally reflected in the other states studied. In all cases, at least 97 percent of the respective state’s GME slots is affiliated with at least one university. However, as in Georgia, both Alabama and Louisiana show most slots overseen by academic institutions. In Louisiana, three‐quarters of state GME positions are distributed relatively evenly across LSU‐HSC New Orleans (29 percent), LSU‐HSC Shreveport (24 percent), and Tulane University (22 percent). Alternatively, of the 89 percent of university‐based residencies in Alabama, the University of Alabama is home to 66 percent, whereas the others are managed by University of South Alabama (20 percent) and, notably, Tuscaloosa College of Community Health Services (3 percent). Based on the information studied, the fate of graduate medical education opportunities is more associated with programs’ affiliations with universities rather management by them. Although an academic health center need not “own” all of its state’s residency slots, residency sites overall are clearly reliant on such organizations to bolster their programs.

NIH Ranks #47‐50

Institutional Characteristics Medical School Founded Location AAHC Member Ownership/Control Relation to Parent University Program Array

AAU Member Practice Plan Location Hospital Name

GHSU 1828 Augusta, GA Yes Public Freestanding/State System Allied Health, Dentistry, Nursing, Grad Studies, Medicine No Medical‐School Based GHS Medical Center

U of Cincinnati 1819 Cincinnati, OH Yes Public Related/Proximate

U of Illinois 1882 Chicago, IL Yes Public Related/Distant

UT Galveston 1891 Galveston, TX Yes Public Freestanding/State System

Allied Health, Grad Studies, Nursing, Pharmacy

Allied Health, Dentistry, Grad Studies, Nursing, Pharmacy, Public Health, Veterinary Yes Medical‐School Based University of Illinois at Chicago Medical Center U of Illinois 182 616 798 1,317 178 247 62 7,805 322 300 877 12,830,632 U of Illinois 45,952,674 197,464,902 86,554,231 67,608,119 17,654,522 47,363,552 55,130,686 889,117 sq. ft. U of Illinois 49 56 92

Allied Health, Grad Studies, Nursing

No Medical‐School Based University Hospital

No Medical‐School Based UT Medical Branch Hospitals at Galveston UT Galveston 123 580 703 933 43 261 240 3,503 229 198 487 25,145,561 UT Galveston $13,843,759 84,781,585 84,063,805 76,644,604 23,623,169 108,714,290 8,725,862 477,271 sq. ft. UT Galveston 50 56 Rank not published

Headcounts 2010 GHSU U of Cincinnati Full‐time Basic Science Faculty 74 154 Full‐time Clinical Faculty 482 1,355 Total Full‐time Medical Faculty 556 1,509 Medical Student Enrollment 770 641 Enrolled Masters Students 1 148 Enrolled Doctoral Students 126 359 Enrolled Postdoctoral Fellows 143 122 Applications 2,142 3,944 Matriculants 230 170 MD Degrees Conferred 180 143 Medical Residents 419 536 State Population 9,829,211 11,536,504 Financials 2010 GHSU U of Cincinnati Med School Total Tuition and Fees $17,772,200 30,791,354 NIH Total Research Funding 44,785,445 92,940,886 NIH Medical School Funding 43,654,047 88,207,437 Med School Government and Parent Support 103,889,527 4,495,428 Revenues from Gifts/Endowments for Med School 9,007,131 58,185,610 Expenditures/Transfers from Hospital Fund to Med Sch 35,783,312 129,510,521 Other Revenues to Med School 4,942,156 20,756,786 Total Research Space 231,929 sq. ft. 832,170 sq. ft. Rankings GHSU U of Cincinnati NIH Awards FY10 70 48 US News Medical School Research 2011 71 42 US News Medical School Primary Care 2011 63 67 Sources: Association of American Medical Colleges, FY2010; Integrated Postsecondary Education Data System FY09; National Institutes of Health Awards 2010; Accreditation Council of Graduate Medical Education (FY10); NSF Research Space Facilities (FY09), NIH Rankings – Blue Ridge Medical Research Institute, 2010; US News and World Report Medical School Rankings, 2011 Note: Rank not published ‐ US News calculated a numerical rank but does not publish it.

NIH Ranks #51‐54

GHSU 1828 Augusta, GA Yes Public Freestanding/State System Allied Health, Dentistry, Nursing, Grad Studies No Medical‐School Based GHS Medical Center GHSU 74 482 556 770 1 126 143 2,142 230 180 419 9,829,211 GHSU $17,772,200 44,785,445 43,654,047 103,889,527 9,007,131 35,783,312 4,942,156 231,929 sq. ft. GHSU 70 71 63

Case Western 1843 Cleveland, OH No Private Related/Proximate Dentistry, Nursing Yes Hospital‐Based Metro Health System Case Western 390 1,633 2,023 822 415 487 495 5,834 199 165 11,536,504 Case Western $48,578,231 155,862,874 140,811,670 3,253,167 48,558,717 171,172,982 7,395,823 434,433 sq. ft. Case Western 51 22 55

UT San Antonio 1959 San Antonio, TX Yes Public Freestanding/State System Allied Health, Dentistry, Grad Studies, Nursing No Medical‐School Based University Health System UT San Antonio 230 894 1,124 907 35 208 128 3,534 220 198 707 25,145,561 UT San Antonio $20,002,540 79,774,009 46,083,133 112,917,502 39,408,141 149,810,983 27,165,345 535,622 sq. ft. UT San Antonio 52 60 33

UT Houston 1972 Houston, TX Yes Public Freestanding/State System Dentistry, Grad Studies, Nursing, Public Health No Medical‐School Based Harris County Hospital District UT Houston 114 803 917 944 21 79 190 3,704 230 188 909 25,145,561 UT Houston $8,894,351 90,675,844 71,789,779 95,624,836 11,317,806 46,062,280 27,798,028 465,173 sq. ft. UT Houston 53 56 Rank not published

UC Irvine 1896 Irvine, CA Yes Public Related/Proximate Allied Health, Nursing, Biological Sciences Yes Medical‐School Based University of California, Irvine, Medical Center UC Irvine 65 587 652 443 20 164 84 4,844 104 109 958 37,253,956 UC Irvine $18,364,760 118,023,946 71,048,232 16,012,767 9,506,254 72,022,829 6,601,268 1,439,038 sq. ft. UC Irvine 54 42 Unranked

Sources: Association of American Medical Colleges, FY2010; Integrated Postsecondary Education Data System FY09; National Institutes of Health Awards 2010; Accreditation Council of Graduate Medical Education (FY10); NSF Research Space Facilities (FY09), NIH Rankings – Blue Ridge Medical Research Institute, 2010; US News and World Report Medical School Rankings, 2011 Note: Unranked ‐ School did not supply enough Information to US News to calculate a ranking. Rank not published ‐ US News calculated a numerical rank but does not publish it.

Appendix 2: Interprofessional Education Literature

Journal

of Interprofessional

November

Care,

informa

2009; 23(6): 621-629

healthcare

The road to collaboration: Developing an interprofessional competency framework

VICTORIA WOODl, ANTHONY FLAVELLl, DORI VANSTOLK2, LESLEY BAINBRIDGEl, & LOUISE NASMITHl I College of Health Disciplines, University of British Columbia, and 2 Project Coordinator for Guided IntelProfessional Field Study (GIFS), BCCH/SHHC, Vancouver, BI'itish Columbia, Canada

Abstract In the absence of an interprofessional competency framework in Canada, the College of Health Disciplines (CHD) at the University of British Columbia developed a universally applicable framework. This article discusses the development of the "BC Competency Framework for Interprofessional Collaboration". Building on a Health Canada funded initiative through the lnterprofessional Network of British Columbia (In-BC), the CHD compared and contrasted existing competency frameworks and consulted curriculum and IP experts throughout British Columbia. The resulting framework is designed to inform curriculum development for health and human service professionals throughout the continuum of learning, starting with pre-licensure education and extending into continuing professional development. The framework will serve as a foundation for future curriculum reform by health and human service educators, practitioners and decision-makers throughout BC and will contribute to the competency literature in Canada.

Keywords: InterprofessiOlzal education, competencies, competency frmneworl?, curriculunl developmem Introduction There is emerging evidence in support of interprofessional collaborative practice as a prime strategy for enhancing patient and health outcomes, and improving retention and recruitment of health and human service providers (Barrett et aI., 2007). In a health care environment faced with patient safety issues, human resource shortages, and populations with increasingly complex health care needs, health professionals must be able to work in collaborative practice models such as interprofessional teams in order to ensure consistent, continuous and reliable care. Interprofessional education (IPE) develops the knowledge, skills and attitudes required by learners and practitioners to effectively work in the health care environment of today and tomorrow. According to Frank (2007), "health professions education is undergoing a 'competency revolution', in which curricula, standards, and assessment are being reoriented to Correspondence: Victoria \'<'ood, MA, Project Research Coordinator, Columbia, Vancouver, Canada. E-mail: viwood@inrerchange.ubc.ea ISSN 1356-1820 printllSSN 1469-9567 DOl: 10.3109/13561820903051477

online ÂŠ 2009 Informa UK Ltd.

College

of Health

Disciplines,

University

of British

622

V Wood el al.

frameworks of applied professional abilities" (p. 3). Epstein and Hundert (2002) define a competency as "the habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served" (p. 226). While there is no widely accepted definition of competency, throughout the literature competencies are defined as either: (i) observable performance; (ii) the standard or quality of the outcome of the person's performance; or (iii) the underlying attributes of a person such as their knowledge, skills and abilities (Hoffnlan, 1999). Which of these three definitions is adopted depends on how the competencies will be used. As the objective of this project was to identify the knowledge, skills and attitudes required for collaborative practice in order to inform health and human service curricula, the third type of definition was needed. Epstein and Hundert's definition was chosen because it takes the notion of knowledge, skills and abilities one step further and specifies the types of knowledge, skills and abilities applied in a health care setting: communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice for the benefit of the individual and the community being served. While it is not the intent of this paper to engage in a lengthy debate about the merits and demerits of a competency-based approach to education, it is important to acknowledge that such a debate exists. To some, a competency is frequently interpreted as a fixed-point, context-free, outcome-based measure (Braithwaite & Travaglia 2005); however, others believe a competency-based approach emphasizes the ability to apply knowledge and skills in the real world and uses performance outcomes as criteria for evaluating learners and education programs (Frank, 2007). Competencies are being increasingly used by many disciplines to comprehensively describe concepts such as interprofessional collaboration. For example the Royal College of Physicians and Surgeons' CanMEDS competency framework has been adopted or modified by nurses, chiropractors, paramedics, physician assistants, family physicians and veterinarians. In order for IPE to be integrated into contemporary health professional curricula, the College of Health Disciplines (CHD) at the University of British Columbia (UBC) identified a need for a commonly agreed upon set of interprofessional competencies. The CHD reviewed the educational literature related to competency-based education and existing competency frameworks and consulted with curriculum developers to identify the process outlined in Figure 1 as a means of comprehensively informing curricula in order to incorporate interprofessional education. The development of a universally applicable interprofessional competency framework was the first step in this process. Using a framework developed by a Health Canada funded project (Guided Interprofessional Field Study) as a foundation, the CHD compared and contrasted existing interprofessional, discipline-specific, and core competency frameworks from Canada, the United States, the United Kingdom, and Australia. After consultation with curriculum and IPE experts throughout BC, a final draft of the 'BC Competency Framework for Interprofessional Collaboration' was developed. This framework is designed to inform curriculum development for health and human service professionals throughout the continuum of learning, from pre-licensure to continuing professional development.

Methods Development of the OfFS Frameworh One project from the Health Canada funded Interprofessional Network of BC (In-BC), the Guided Interprofessional Field Study (GIFS), focused on the development of a competency assessment tool for interprofessional collaborative practice at a tertiary acute paediatric and

Developillg an interprofessional competency frameworh

in IP

623

, ,

IP curriculum Outcomes Gaps .- Learning Define IP Objectives Learning Framework Experiences Performance Competency· ..··..·..·..·....·· of Learner I of Learner .It

Curricula

Figure I. Reforming

[;alUatiOC

health and human service curricula to incorporate

interprofessional

education.

women's health facility. The project engaged field practitioners in Continuous Quality Improvement (CQI) initiatives to discover solutions by working together. The project group, which comprised parents (patients), as well as professionals and students from various professions, immediately identified the need to articulate interprofessional competencies in order to set the standards for CQI team effectiveness. The competency development process consisted of three main components: reviewing supporting literature and standards of practice from all the professional associations; individual and group dialogue with various professions; and development of a compctency assessment tool. First, the professional associations' professional standards, codes of ethics, and national essential competencies were reviewed in order to examine collaborative practice competencies. A list of proposed competencies was generated after reviewing these documents. Second, face-to-face conversations and interviews were conducted with professionals from medicine, social work, nursing, psychology, pharmacy, and child life in order to learn more about their individual professional standards and their experience with collaboration and communication. The interviews focused on how, as a professional, they became competent in various domains of collaborative practice. The information gathered informed a forum in which over 50 participants, consisting of novice and experienced practitioners representing 14 different professions as well as students and parents (patients), rotated through a series of stations at which the competencies needed for collaborative practice in a particular context were discussed. For example, one station discussed the competencies needed for collaboration during a one-off, 10-15 minute encounter between different professionals not part of a formalized team. As groups rotated through the stations, discussions were documented with each group building on the work of the previous group(s). The information from the forum was collated by three nursing students and then analyzed by a small working group of practitioners and parcnts. The results of the interviews and forum informed the development of the descriptors and behavioural indicators of ~ach competency in a draft "Compctency Assessment Planning and Evaluation (CAPE) Tool". A second group 01'25 participants from nine different professions was asked to provide feedback on the CAPE Tool. Nursing students verified the competencies in the field by shadowing other professionals and observing how the practitioners demonstrated behaviours articulated in the competency assessment tool. The nursing students also interviewed parents (patients) about their experience with the healthcare team and their perceptions of collaborative

624

V Wood et al.

practice. The results of these interviews were incorporated into the final draft of the interprofessional competency assessment tool, which was organized into six domains: • •

•

Domain I: Relational Work - Definilion: Establish and/or maintain healthy working relationships with patients/families, other professionals and teams. Domain II: Roles and Responsibilities - Definition: Consult, seek advice and confer with other professionals based on clear understanding of their capabilities and expertise. Domain III: Partnering - Definition: Establish and maintain effective working partnerships with patients/families, other professionals, teams or organizations to achieve common goals. Domain IV: Patient/Person/Family-Centred Care - Definition: Provide integrated care that is respectful of and responsive to patient/client/family perspectives and needs and ensure that patient/client/family values guide all clinical decisions. Domain V: Information Management and Exchange - Definition: Use communication systems and tools (including technology) to exchange relevant information among all professionals to improve care. Domain VI: Quality Improvement - Definition: Work with patients/families and other professionals to examine outcomes and implement quality improvement initiatives to mitigate errors, reduce waste, increase efficiency and minimize delays.

The GIFS project shared this tool with the CHD through the Interprofessional Network of BC (In-BC). The CHD decided to develop a more widely applicable framework and to use the GIFS interprofessional competency assessment tool as a foundation for the "BC Competency Framework for Interprofessional Collaboration". Developmelll of the BC Competency Frameworl? The process used to create a competency framework for interprofessional collaboration is outlined in Figure 2. In addition to the GIFS framework, the CHD compared and contrasted existing interprofessional and core competency frameworks (see the Appendix for a list of frameworks). Some of these frameworks are specifically interprofessional, many using the collaborative competencies identified by Barr (2005) as a foundation. Other frameworks define core competencies which identify the knowledge, abilities, and expertise in a specific subject area or skill set that are shared across the health and human service professions. One framework examined identifies interprofessional capabilities rather than competencies; however, using Epstein and Hundert's definition of competency is broad enough to encompass the concept of a capability. By examining the language, consistencies, inconsistencies, overlap, and discrepancies among existing frameworks, a first draft of the "BC Competency Framework for Interprofessional Collaboration" was developed. In its first iteration 23 competencies, each with several associated indicators, informed by the frameworks reviewed, were divided into five domains informed by the GIFS framework, the third domain having three subsections: • • •

Domain I: Interpersonal and Communication Domain II: Patient-Centred Care Domain III: Collaborative Practice

Skills

Developing

an imerprofessional

competency fra1l2eworl?

625

Competency Framework

Domain Definitions: I. Interpersonal and Communication Skills II. Patient-Centred and Family-Focused Care III. Collaborative Practice A) B) C) D)

20 Competencies (+ Associated Indicators)

Collaborative Decision-Making Roles and Responsibilities Team Functioning Continuous Quality Improvement

Competency Framework for Interprofessional Collaboration

Figure 2. Creating a competency

• •

framework for inrerprofessional

collaboration.

Subsection A - General Collaboration Subsection B - Roles and Responsibilities Subsection C - Team Functioning Domain IV: Information Management and Exchange Domain V: Continuous Quality Improvement

This initial draft of the competency framework was presented to interprofessional education and curriculum experts from the British Columbia health authorities and the health and human service programs at UBC. Several representatives from these groups participated in an intensive face-to-face session to review the draft document. Modifications to the document were incorporated following this consultation and the modified document was presented electronically to a group representing IPE and curriculum experts throughout the province. In addition, several IPE experts from across Canada were approached for feedback. Feedback from these consultations was incorporated into the final draft of the "BC Competency Framework for Interprofessional Collaboration".

Results The final version of the "BC Competency Framework for Interprofessional Collaboration" organizes 20 competencies and their associated indicators into three domains: • •

Domain I: Interpersonal and Communication Skills Domain II: Patient-Centred and Family-Focused Care

626 â&#x20AC;˘

V Wood et al. Domain

III: Collaborative

Subsection Subsection Subsection Subsection

A B C D

Practice

Collaborative Decision-Making Roles and Responsibilities Team Functioning Continuous Quality Improvement

The 20 competencies were taken from those which were most consistent across the majority of the existing frameworks explored. Each was modified so the language used was explicitly interprofessional. Throughout the development of the framework the focus was to identifY what an effective collaborative practitioner looks like in the practice setting; therefore, the competencies are also articulated in the language of practice. Combined, the competencies describe the essential characteristics of effective collaboration and are flexible enough to apply to any setting. The domains, the competencies that appear under each, and the order in which they are presented were informed by the consultations. Interpersonal and Communication Skills and Patient-Centred and Family-Focused Care encompass more generic competencies that act as prerequisites for interprofessional collaborative practice competencies. These are skills that are also necessary elements of general practice and therefore not unique to interprofessional collaboration. Interpersonal and Communication Skills ensure health care providers consistently communicate sensitively in a responsive and responsible manner. PatientCentred and Family-Focused Care involves working with others to negotiate and provide optimal, integrated care by being respectful of and responsive to patient/client and family perspectives, needs, and values. However, the competencies in both domains identifY the knowledge, skills and attitudes specific to interprofessional collaboration, such as the ability to effectively express one's own knowledge and opinions to others involved in care and involving the patient/client and family as partners in group decision-making processes. Subsequent domains become more specific to interprofessional collaboration. Collaborative Practice competencies ensure practitioners establish and maintain effective working partnerships with other professionals, patient/clients, families, other teams, organizations, and individuals to achieve common goals. The sub-domains under Collaborative PraClice define the necessary components of effective collaboration between both formal and informal teams. Collaborative Decision-Mahing defines the competencies necessary to establish and maintain effective and healthy working partnerships with other professionals, whether or not a formalized team exists. Team Functioning involves team building skills to negotiate, manage conflict, mediate between different interests and facilitate building of partnerships within a formalized team setting. An understanding of the Roles and Responsibilities of other professions is a key component of any interprofessional collaboration. Practitioners should consult, seek advice and confer with other team members based on a clear understanding of everyGne's capabilities, expertise and culture. Finally, Continuous Quality Improvement encompasses the competencies which are most specifically interprofessional as it is an activity that requires effective collaboration on the part of an interprofessional team to complete. Health care professionals must work with an interprofessional team to contribute to continuous improvement of the health care system, particularly in the area of patient/client safety by mitigating errors, increasing efficiency, and minimizing delays.

Discussion The "BC Competency Framework for Interprofessional Collaboration" is designed to inform curriculum development and practice for health and human service professionals

Developing an imerprofessional competency frameworh

627

throughout the continuum of learning, from pre-licensure to continuing professional development. Ideally, students who have achieved both their profession specific competencies and the interprofessional competencies will be prepared to practice effectively in the health care environment of today and tomorrow. It is hoped that this framework will provide a foundation for future curriculum and practice reform by health and human service educators, practitioners and decision-makers throughout BC and contribute to a national framework in Canada. \X1hilecompetency-based training suggests that competencies are what we want trainees to attain, Ten Cate (2006) suggests performance involves more than achieving competencies. The identification of competencies is just the first step of many in ensuring that future health care providers are prepared to deliver quality health care. According to Wright et al. (2000), frameworks that identify the competencies necessary for effective practice provide a foundation for operationalizing teaching objectives based on the knowledge, skills, and attitudes underpinning each competency. The outcome evaluation methods, including the appropriate related measures of performance then need to be developed and implemented. According to Greiner and Knebel (2003), there are three questions that educational institutions must answer when developing competency-based health professional curricula: (1) (2) (3)

What order What How

knowledge, skills, and professional/personal values should graduates have to be prepared for practice? learning experiences will enable students to acquire these competencies? can these competencies be assessed?

111

Through the development of the "BC Competency Framework for Interprofessional Collaboration", the CHD set out to answer the first question, identifying the knowledge, skills and values that practitioners need in order work interprofessionally, enabling them to provide consistent, continuous and reliable care. Subsequent phases of this project address the other two questions, exploring what learning experiences might facilitate the acquisition of the competencies and how best to evaluate whether or not students have attained them.

Conclusion Interprofessional education (IPE) strategies can contribute to the development of the knowledge and skills required by learners and practitioners to effectively work in today's health care environment, but only if the goals of IPE are agreed upon, the desired outcomes are clearly specified, the most effective methods of delivery are determined, and robust evaluation is incorporated. An interprofessional competency-based approach offers an explicit framework to initiate, develop, implement, and evaluate the processes and outcomes orIPE. The essential competencies needed for practice must be defined and interventions implemented to ensure their adoption. The competency framework will help to embed IPE in curricula and practice.

Acknowledgements This project has been supported by Health Canada's Interprofessional Education for Patient-Centred Practice Strategy. The BC Competency Framework for Collaborative Practice can be found at www.chd.ubc.ca/competency

Declaration of intel'est: The authors report no conflicts of interest. The authors alone are responsible

for the content and writing of the paper.

628

V. Wood et aZ.

References Accreditation Council of Graduate Medical Education (ACGME) (1999). 01llcome ProJecr: General Competellcies. http://www .acgme. org/ ou tcome/ co mp/compfv1in. asp Barr, H. (2005). buerprofessional education. Today, yesterday and tolllorrow. A review. London: UK Centre for the Advancement of Interprofessional Education. http://www.caipe.org.uk Barrett,.J., Curran, V., Glynn, L., & Godwin, 1\1. (2007). CHSRF sYlllhesL~:bltelprofessimwl collaboratioll and quality primary healthcare. Ottawa: Canadian Health Services Research Foundation. www.chsrf.ca Braithwaite, J., & Travaglia, J. (2005). The ACT Health interprofessionallearning and clinical education project: discussion paper #2, 1-16. Canberra: ACT Health Department. Canadian Interprofessional Health Collaborative (CIHC) (2007). /Illerprofessional education and core competencies: A literature review. www.cihc.ca Canadian Patient Safety Institute (CPSI) (2008). The safely competencies: Enhmlcing palicl1l/clielll safety across the hcalth profcssions. http://www.patientsafetyinstitute.caluploadedFiles/Safety _ Competencies_16Sep08. pdf Combined University Interprofessional Learning Unit (CUILU) (2004). A framework col1laining capabilities and leaming levels leading to illlclprofessional capability. http://www.cuilu.group.shef.ac.uk/capabilityjramewor1cpdf Epstein, R., & Hundert, E. (2002). Defining and assessing professional competence. Joumal of the American Medical Associalion, 287, 226-235. Frank, J. (2007). Nledical leadership awl effecrivc illlerprofessional health care teams: A compctcllcy-based approach. Vancouver: IMWC. Greiner, A., & Knebel, E. (Eds.) (2003). Health professions edllcalion: A bridge 10 qllali(v. \'\Tashington, DC: Institute of Medicine of the National Academies. Hottman, T. (1999). The meaning of competency. JOllnzal of /;'uropean bldllsm路al Tranillg, 23(6), 275-285. Pruitt, S., & Epping-Jordan, J. (2005). Preparing the 21st century global health care workforce. British Medical JOllmal, 330, 637-639. Royal College of Physicians and Surgeons of Canada (2005). CmuHEDS Physician COl1lpelency Framework. http:// rcpsc. med ical. org/ canm eds/bes tpracti ces/fram ework_ e. pd f Ten Cate, O. (2006). Trust, competence, and the supervisor's role in postgraduate training. 13rilis/zNledical JOllmal, 333, 748-75l. University of Minnesota (1996). A reporl by the Academic lIealth (7e11lerTask Force 011 /lIlerdisciplinalY lIealth Team Development. http://www.ahc.umn.edu!tflihtd.html University of Toronto. (n.d.). Health professional collaborator compctencies. http://ipe.utoronto.ca/Educators/ competencies.htm Wright, K., Rowitx, L., Merkel, A., Reid, \'\T., Robinson, G., Herzog, B., Weber, D., Carmichael, D., Balderson, T., & Baker, E. (2000). Competency development in public health leadership. American Joumal of Pllblic Heal1h, 90(8), 1202-1207.

Appendix List of competency frameworhs compared and contrasted (1) (2) (3) (4) (5) (6) (7) (8)

The CanMEDS Physician Competency Framework (Royal College of Physicians and Surgeons of Canada, 2005) The ACT Health Interprofessional Learning And Clinical Education Project Competencies (Braithwaite & Travaglia, (2005) The Combined Universities Interprofessional Learning Unit (CUILU) Interprofessional Capabilities Framework (2004) Canadian Patient Safety Institute (CPSI) Safety Competencies (2008) Institute of Medicine (10M) Core Competencies (Greiner & Knebel, 2003) lnterprofessional Education Consortium (lPEC) Core Competencies (2002) (in CIHC, 2007) Pew Health Professions Commission Core Competencies (1998 in CIHC, 2007) Accreditation Council of Graduate Medical Education (ACGME) Minimum Program Requirements (1999)

Developing an interprofessional competency frameworl? (9) (I 0) (I1) (I 2)

University of University of World Health patients with Collaborative

629

Minnesota Core Competencies Adopted (I996) Toronto Health Professional Collaborator Competencies (n.d.) Organization core competencies for delivering effective health care for chronic conditions (Pruitt & Epping-Jordan, 2005) competencies developed by IPE, according to Barr (2005)

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PATTERNS

Interprofessional Healthcare: A Common Taxonomy to Assist with Understanding A/ice B. Aiken, PT, PhO Mary Ann McColl, PhO

Implementation

of models of interprofessional

healthcare

can be a

difficult process. One of the contributing factors is that different professionals use different terminology when addressing the same concepts. This paper proposes a common

taxonomy

professional

understanding

care in order to facilitate

regardless of the health described Triage

with specific Model,

and

professions examples: Parallel

involved.

for models of inter-

the Physician Model.

of these models

Three

basic models are Extender

Allied

Health

Model,

2009;

38:e92-e96.

the healthcare system, it must incorporate multiple solutions so all areas of the health care continuum can be addressed. The goal of this paper is to provide a summary of the three main models of interprofessional care that have been shown to be effective in improving healthcare delivery in a variety of settings. It is only through a complete understanding of interprofessional care that its implementation will be enhanced and facilitated and this can be facilitated through a common taxonomy for models of care.

Background In order to address problems with access-to-healthcare issues many institutions have begun to examine interprofessional models of healthcare. One important aspect of interprofessional care is to ensure that the most appropriate healthcare provider is assuming responsibility for care within the domain of their discipline-better ensuring that the right care is provided by the right provider at the right time and place. Depending on the domain of the healthcare service, the interprofessional team usually includes at least one member of an allied health profession, as well as a physician. These providers work collaboratively to provide the necessary care for the patients, incorporating their own unique skill set into the provision of care in order to maximize effectiveness of the system and to ultimately provide better care. Improved use of non-physician healthcare providers can have a positive impact on the cost of health care, I on efficiency of the healthcare system in terms of health human resources,2,3 on patient satisfaction with care,4,S and on physician productivity and satisfaction with the work environment.6-S One of the pitfalls in the implementation of interprofessional care is the focus tends to be on only one model, without recognition of the value of multiple models of care for a variety of different settings. If change is to be implemented in

Dr. Aiken is an Assistant Professot, School of Rehabilitation Therapy, and Dr. McColl is Associate Director, Centre for Health Services and Policy Research, Queen's University, Kingston, Ontario, Canada. PP827 - Received Aug 12,2008; accepted Jan 15,2009. Addtess correspondence to: Alice B. Aiken, School of Rehabilitation

Ther-

apy, Queen's University, Kingston, ON K7L 3N6, Canada. Tel 613-5336710; fax 613-533-6776; e-mail: alice.aiken@queensu.ca.

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The major focus of models of interprofessional care IS lITIprovement of the delivery of health services through the use of allied health professionals in the existing healthcare system. Since this notion was first conceived, there have been a number of different professionals involved in working collaboratively and a number of different models for conceptualizing their relationship with physicians.9 Over time, these professionals have provided an increasing number of healthcare services that in the past had been exclusively provided by physicians.1,lO As healthcare shifts to team-based practices, the opportunities for distributing patient care responsibilities among different disciplines increases. I ,II These professionals may also be those whose scopes of practice arc most consistent with a specific portion of the medical services provided by physici;ms, but whose scopes of practice also include duties that me unique to their professions; thus a more comprehensive program of care can be offered to the patient. 1,5.10,12 The care provided by these professionals has been found to be cost effective and satisfactory to patients; therefore, more clinics and group practices are incorporating allied health professionals into interprofessional models ofhealthcare.1,12-l4 In discussing models of interprofessional care, several factors are key to defining the different models. These are: 1. the location of practice, either in hospital, clinic, or community settings; 2. governing principles that allow allied health professionals to practice in models of interprofessional care; 3. the framework that defines the scopes of practice of the health professionals; 4. degree of shared patient liability; and 5. the effectiveness and efficiency of the models fessional care.

of interpro-

AIKENANDMCCOLL, Taxonony of Inrerprofessional Healthcare

= physician

0:= FIGURE

I. The

professional othcr health

Physician Extender Model of interprofessional care.

From a review of the current literature on interprofessional practice, three basic models of care have been found and formed into an original taxonomy. They have been named the Physician Extender Model, the Triage Model and the Parallel Model. Each will be discussed in terms of organization and effectiveness.

Interprofessional

Healthcare Models

THE PHYSICIAN EXTENDER MODEL In the physician extender model of care the allied health professional's scope of practice fits entirely within the physician's scope of practice. This model generally exists in primary care, where the physician and the allied health professional are colocated in a clinical environment and the health professional is employed to assist the physician with routine medical and managerial tasks. This model of care is illustrated in Figure 1. The goal of such a model of care is to allow the physicians to have more time to spend seeing patients and performing complex medical duties. I Physician extenders work directly with physicians in most areas of healthcare, and they perform tasks normally performed by physicians. As a result their employment meets with high levels of physician satisfaction.ls Their work also meets with high patient satisfaction, and provides reduced healthcare costs for patients and institutions.16.20 Physician extenders can be used to fill service gaps caused by physician maldistribution.ls,19 Physician assistants, healthcare professionals commonly found working in physician extender models of care, have been shown to be capable of handling 80% of the services required to manage patient problems in primary care, at physician-equivalent levels of quality of care.19 This has been shown to be satisfactory to physicians because their patients get similar quality of care, they can oversee more patients in a shorter period of time, and the physician retains ultimate control of the clinics and pmient services by being the supervisor of the physician assistant.21 When patients were screened by physician assistants in a trauma center, the severity of the injuries (based on a standardized score) seen by the physicians increased by 19%, which was perceived by the physicians as a more efficient use of their time and a better distribution of resources. 19 Patient satisfaction is consistently reported to be high with the use of physician assistants.16.19,n,23 Within their area of

Journal of Allied Health, Fall 2009, Volume 38, Number 3

competence, physician assistants have been reported to provide a quality of care indistinguishable from care provided by physicians. IS Physician assistants perform duties at a similar level to junior physicians and residents, and are thought to act interchangeably at the patient level.20 In a study of patient satisfaction with the use of a physician assistant as a physician extender to "fast-track" patients in an emergency department in the U.s., Counselman and colleagues (2000) found high satisfaction with the service provided by the physician assistant. In addition, only 12% of the patients indicated that they would have preferred to wait longer to be seen by an emergency physician.16 In a U.S. national cross-sectional study on satisfaction, physici<ln assistants were rated as favorably as physicians for primary care purposes.17 Interestingly, it has also been reported that while patients were satisfied with physician assist<lnt involvement in their healthcare, they did not expect physician assistants to be experts.23 This indicates that while satisfaction is high, patients may have different expectations from physician assistants than they do from physicians, and therefore may use different criteri<l by which to judge the assistants. I7,23 Physici<ln extenders are also reported to be cost effective. Physician assistants can relieve physicians of routine duties and procedures, thereby freeing up physici<ln time, and providing care at about one-third the cost of a physician.20 One of the primary ways in which physician extenders can represent <I cost savings to physicians is by incre<lsing the number of patients seen on a given day. In a comprehensive survey, it was found that physician assistants working in primary care inp<ltient settings saw an average of 15.7 more patients per day over and above what the physicians saw, and those in outpatient settings saw an average of 22.1 more patients per day, thereby increasing the physicians' through-put significantly. IS Ackermann and Kemle (1998) used a geromologist physician assistant as a physician extender to perform nursing home visits three to four times per week to provide all care to the residents, though the physician still visited all pmients m regular intervals. After the introduction of the physician assistant, hospital admissions were decreased 38%, the total number of hospital days per 1000 patient years decreased 68.6%, and total number of nursing home visits by a healthcare professional increased by 62.1 %. Although the charges for physician and physician assistants to Medicare increased by $22, 304.00, this was more than offset by an estimated decline in hospital costs of $96, 043.00.n In a study to determine the effectiveness of using a physician extender in a trauma service, Miller and colleagues (I998) found that hospital costs were dramatically reduced when a nurse employed as a physician extender was utilized. The cost savings came in the form of reduced hospital costs from faster patient flow. They found a decrease in transfer times from the emergency department to the operating room of 43%, to the intensive care unit of 51 %, and to the floor of 20%. In addition, the average length of stay of patients in the intensive care unit decreased from 8.7 to 6.2 days. They concluded that the use of a nurse as a physician extender in a

e-93

physician

O路

= prnlessional olher health

FIGURE

2. The Triage Model of interprofessional care.

trauma service improved

the effectiveness

of the service.19

Therefore, it can be seen that the physician extender model of interprofessional care is a highly effective one. Patients and physicians both report high levels of satisfaction with the model of care and cost savings to the healthcare system can be significant. THE TRIAGE

MODEL

The triage model of interprofessional care involves using other health professionals to perform preliminary assessments on patients, to triage patients for physician assessment, and to perform conservative management on those patients who require it before they are seen by the physician.2,19,24 Such a model of care can be found in emergency departments, trauma departments, or tertiary care settings. This model usually necessitates that the physician and the other health professional are co-located. These other health professionals may also require advanced training in the medical area in which they are employed, and in the interpretation of diagnostic tests. The triage model of care is illustrated in Figure 2. The purpose of the triage model of interprofessional care is to improve patient through-put in busy healthcare settings, 19,24and to allow patients to access the appropriate management for their problem in a more timely fashion than waiting to see a physician first.2 The impact of the triage model of care on the healthcare system is enormous in terms of resource utilization and improved patient care. The effectiveness of the model is measured in terms of reduced wait times, reduced length of hospital stay, patient satisfaction, physician satisfaction and cost for care.2,24路26 In trauma units in hospitals

in the United

States, the use

of triage models of interprofessional care involving nurse practitioners has cut in half the transfer time from presentation to either the operating room or the intensive care unit. 19 Similar reductions in patient wait times for services were found when nurses were used to interpret X-rays in an emergency department; this led to patients receiving treatment at an earlier stage and experiencing shorter wait times.26 Bethel and colleagues (2005) determined that the use of a physiotherapist in an emergency department to triage orthopedic complaints allowed physicians to deal with more serious medical conditions.27 Christmas and colleagues (2005) found another positive effect of using a triage model of interprofessional care was that length of stay in the intensive care unit, transfer time to a

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floor, and overall length of stay in the hospital were reduced. When nurses were incorporated into a trauma program, a 13% decrease in total hospital length of stay, a 20% decrease in transfer time to the floor, and a 33% decrease in length of stay in the intensive care unit were reported. The reasons for this dramatic change in patient through-put was due to the nurses being available to patients to provide conservative management as discharge planners and social services coordinators and for other patient care issues that may arise.S,19,24 This allowed patients' needs to be addressed in a more immediate fashion, reduced patient and family anxiety, and reduced length issues. s, 1 2

of stay by avoiding

waits for patient

care

One area where the triage model of care has been successful is with the utilization of physiotherapists to triage patients in orthopedic clinics. This model of care has been shown to reduce wait times for major joint replacement surgery,2S,29 improve patient satisfaction with conservative management strategies that they are offered,3o.32 and represent a substantial cost savings to publicly funded healthcare systems)3,34 In addition, the diagnostic capabilities of physiotherapists have been shown to be equal to that of orthopedic surgeons)5,36 Physician satisfaction with triage models of interprofessional care has also been reported to be high. In some settings, the allied health professionals have assumed roles previously performed by physicians, such as routine care, and this has an impact on how physicians practice.l As a result, physiCians have started focusing on the more complex medical nature of practice and the allied health professionals assume the care role and spend more time talking with patients. This appears to be satisfactory to physicians. I In a comparison of cost effectiveness between registered nurse first assistants and physician surgical assistants in triage models in operating rooms in Canada, based on monetary rewards alone, the nurses provided significantly more costeffective care)7 Christmas and colleagues (2005) found that adding two nurse practitioners to a trauma service, in a triage model of care, at the cost of $135,580 (US) per year did not increase the cost per patient because of the reduced length of stay of the patients and the reduced medical burden on the hospital afforded by these two nurses.24 Therefore it can be seen that a triage model of interprofessional care meets with patient and physician satisfaction. This model has also been shown to reduce the length of hospital stays and decrease hospital costs. THE PARALLEL MODEL In the parallel model of care an allied health professional has some shared duties with the physician, and some duties independent from the physician. This model for interprofessional care can exist in primary, 8 secondary, 37 or tertiary 4 healthcare settings. This model is illustrated in Figure 3. In the parallel model of care, the allied health professional will typically have advanced training, and limited authorized powers of prescription and the ability to order diagnostic

AIKENAND McColl,

Taxonomy of Interprofessional I-Iealthcare

o FIGURE 3. The

Parallel Model of interprofessional

'" physician '" other health professional

care.

tests.38 The professional will be part of a healthcare team, but may spend much of the time practicing autonomously. The allied health professional in this model has advanced training in a particular clinical area, and assumes the responsibility for a number of medical and health procedures normally performed by the physician. They also offer a range of services that would not be offered by the physician but are of benefit to the patient such as wellness education, lifestyle counseling and self-management strategies.39 The impact of parallel models of care is significant in terms of resource utilization, access to healthcare, and cost effectiveness on the overall healthcare system. Patient satisfaction is very high with parallel models of interprofessional care, and patients are equally satisfied with being assessed by a physician or another health professional in a variety of settings. 1,12,25,40,41

In a study of military patients receiving neuromusculoskeletal care from physiotherapists with limited powers of prescription, Benson and colleagues (1995) found that patient satisfaction was high with these specially trained physiotherapists. They concluded that practice was safe for patients and that it improved the dispersion of limited medical resources in isolated areas.42 In a study of the satisfaction of pediatric rheumatology patients receiving care from a specially trained physiotherapist, Ayling-Campos and colleagues (2002) found that there was improved patient and parent satisfaction with having the physiotherapist and a rheumatologist as care providers. They concluded that physiotherapists in this role met consumer needs.4J,44Patient satisfaction has been related to experiencing less waiting time for an appointment, longer time with a healthcare professional when they are seen, and improved continuity of care if the patient is managed by a physiotherapist-physician team.25 Mundinger and colleagues (2000) randomized 1316 patients who did not have a family physician and presented to emergency to receive ongoing care from either an advanced practice nurse (n = 806) or a physician (n = 510). They found no differences in utilization rates, health status or patient satisfaction between the two groups.12They concluded that in a situation where advanced practice nurses had the same authority, responsibilities, productivity and administrative requirements as physicians, they provided a service in which outcomes such as patient satisfaction were comparable.12 An area that has been reported favorably for parallel models of care is that of cost effectiveness.U5 It has been reported that the use of advanced practice nurses can save the health-

Joumal of Allied Health, Fall 2009, Volume 38, Number 3

care system money in terms of the salary of the individual performing the medical intervention.I,25 If an advanced practice nurse is more readily available to perform procedures, hospital costs per patient will decrease.12 A four-year retrospective study demonstrated that advanced practice nurses were able to develop marketable services that were not previously offered to patients and resulted in cost savings for medical practices.25 Therefore, it can be seen that parallel models of interprofessional care meet with patient satisfaction, improve efficiencies in terms of time and cost, and offer new and emerging services to the helllth consumer.

Discussion Although health professionals have been working in models of interprofessional care since the 1960s, generally these models are institution specific or designed as trial projects with little uniformity among the professions as to the form these models should take. Three basic models of interprofessional care have been found in the current literature and are named the Physician Extender Model, in which the healthcare provider works under the direction of the physician to perform duties normally performed by the physician; the Triage Model, in which the provider screens patients for potential management by the physician, and manages those cases where the patients do not need to see the physician; and the Parallel Model in which the provider works autonomously, seeing patients in order to expand the availability of healthcare services. In the latter two models of care, providers offer expanded care, based on their expertise, so that the patients have more treatment options or alternative management strategies than may have been provided by the physician alone. CONCLUSION

It is only through a complete understanding of the literature surrounding models of interprofessional care that appropriate changes can be facilitated. Lack of uniformity in structure and not using a common taxonomy in the design of models of interprofessional care have been identified as problems linked with the implementation of these programs.45 It is essential to recognize that there are several models of care that can be of benefit to the healthcare system, and to choose the most appropriate model for a specific environment. Through a common taxonomy, healthcare providers can speak the same language when describing interprofessional models of care, and improved understanding and implementation can occur. REFERENCES I. Cooper RA. Health care workforce for the twenty-first century: the impact of nonphysician clinicians. Annu Rev Med 2001; 52:51-61. 2. Ganapathy S, Zwemer FL, Jr. Coping with a crowded ED: an expanded unique role for midlevel providers. Am J Emerg Med 2003; 21 (2): 125128. 3.

llmpka T, Svensson B, Molin B. Development of community nursing:

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analysis of the central services and practice dilemmas. Int ) Nurs Stud 1996; 33(3 ):297-308. 4.

Derengowski SL, Irving SY, Koogle PV, Englander RM. Defining the role of the pediatric critical care nurse practitioner in a tertiary care center. Crit Care Med 2000; 28(7):2626-2630.

5. van Soeren MH, Micevski V. Success indicators and barriers to acute nurse practitioner role implementation Clin Issues 2001; 12(3):424-437.

in four Ontario hospitals. AACN

6. Carr), Armstrong S, Hancock 13,Bethea). GPs' perceptions of the nurse practitioner role in primary care. Br) Commonity Nurs 2002; 7(8):408413. 7. MacDonald), Katz A. Physicians' perceptions of nurse practitioners. Can Nurse 2002; 98(7):28-31. 8. Rodysill K). Increasing physician productivity using a physician extender: a study in an outpatient group practice at the Mayo Clinic. ) Med Pract Manage 2003; 19(2):110-114. 9. American Academy of Physician Assistants. Physician assistant and nurse practitioner workforce trends. Am Fam Physician 2005; 72(7):1 176. 10. Cooper RA, Henderson T, Dietrich CL. Roles of nonphysician clinicians as autonomoos providers of patient care. )AMA 1998; 280(9):795-802. II. Coile RC,)r. Integration, capitation, and managed care: transformation of nursing for 21st century health care. Adv Pract Nurs Q 1995; 1(2):7784. 12. Mundinger MO, Kane RL, Lenz ER, Totten AM, Tsai WY, Cleary PO et al. Primary care outcomes in patients treated by nurse practitioners or physicians: a randomized trial. )AMA 2000; 283( 1):59-68. 13. Crane Sc, PAs/NPs: forging effective partnerships in managed care systems. Physician Exec 1995; 21(10):23-27. 14. Pan S, Geller )M, Gullicks )N, Muus K), Larson AC A comparative analysis of primary care nurse practitioners and physician assistants. Nurse Pract 1997; 22(1):14,16-14,17. 15. American Academy of Physician Assistants. American Academy of Physician Assistants Website. www aapa org 2006 16. Counselman FL, Graffeo CA, Hill)T Patient satisfaction with physician assistants (PAs) in an ED fast track. Am) Emerg Med 2000; 18(6):661665.

17. Hooker RS, Cipher D), Sekscenski E. Patient satisfaction with physician assistant, nurse practitioner, and physician care: a national survey of Medicare beneficiaries.) Outcomes Measurement 2005; 12(2):88-92. 18. Jones PE, Cawley )E Physician assistants and health system reform. Clinical capabilities, practice activities, and potential roles. )AMA 1994; 271 (16): 1266-1272. 19. Miller W, Riehl E, Napier M, Barber K, Dabideen H. Use of physician assistants as surgery/trauma house staff at an American College of Surgeons-verified Level II trauma center. ) Trauma 1998; 44(2):3 72-3 76. 20. Stewart A, Catanzaro R. Can physician assistants be effective in the UK? Clin Med 2005; 5(4):344-348. 21. Fetraro KF, Southerland T. Domains of medical practice: physicians' assessment of the role of physician extenders. ) Health Soc Behav 1989; 30(2): 192-205. 22. Ackermann Rj, Kemle KA. The effect of a physician assistant on the hospitalization of nursing home residents. ) Am Geriatr Soc 1998; 46(5):610-614. 23. Elizondo E, Blessing )0. The ability of PAs to solve patients' psychosocial problems. A preliminary report on patient expectations. Physician Assist 1990; 14(2):75-82. 24. Christmas AB, Reynolds ), Hodges S, Franklin GA, Miller FB, Richardson )0 et al. Physician extenders impact trauma systems. ) Trauma 2005; 58(5):917-920.

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25. D'Angelo L, Reifsteck SW, Green RD. Nurse practitioners--co-providers of health 26. Summers Accident 27. Bethel ).

care. Med Group Manage 1984; 31 (3 ):38-44. A. Can nurses interpret X-rays safely without formal tuition? and Emerg Nurs 2005; 13:162-166. The role of the physiotherapist practitioner in emergency

depattments: A critical appraisal. Emerg Nurse 2005; 13(2):26-31. 28. Aiken AB, Atkinson M, Harrison MM, Hope ). Reducing hip and knee replacement wait times: an expanded role for physiotherapists in orthopedic surgical clinics. Healthc Q 2007; 10(2):88-91,6. 29. Aiken AB, Harrison MM, Atkinson M, I-lope ). Easing the burden for joint replacement wait times: the role of the expanded practice physiotherapist. Healthc Q 2008; 11(2):62-66. 30. Byles SE, Ling RSM. Orthopaedic out-patients -- a fresh approach. Physiotherapy 1989; 75(7):435-437. 31. Daker-White G, Carr AJ, Harvey 1, Woolhead G, Bannister G, Nelson I et al. A randomised controlled trial. Shifting boundaries of doctors and physiotherapists in orthopaedic outpatient departments. J Epidemiol Community Health 1999; 53(10):643-650. 32. Durrell S. Expanding the scope of physiotherapy: Clinical physiotherapists in consultants' clinics. Manual Therapy 1996; 1(4 ):210-213. 33. Gardiner j, Wagstaff S. Extended scope physiotherapy: the way towards consultant physiotherapists? Physiotherapy 2001; 87( I ):2-3. 34. Hackett GI. Hudson MF, Wylie JB, Jackson AD, Small KM, Harrison P et al. Evaluation of the efficacy and acceprabiliry to patients of a physiotherapist working in a health centre. Br Med J (Clin Res Ed) 1987; 294(6563 ):24-26. 35. Aiken AB, McColl MA. Diagnostic and treatment concordance between a physiotherapist and an orthopedic surgeon--a pilot study. ) lnterprof Care 2008; 22(3 ):253-261. 36. Gardiner J, Turner P. Accuracy of clinical diagnosis of internal derangement of the knee by extended scope physiotherapists and orthopaedic doctors: retrospective audit. Physiotherapy 2002; 88(3):153-157. 37. Groetzsch G. Show me the money! Factors to consider when looking to finance a RNFA position. Can Oper Room Nurs J 2004; 22(4 ):23-4,38. 38. Edwards JB, Oppewal S, Logan CL. Nurse-managed primary care: outcomes of a faculty practice network. J Am Acad Nurse Pract 2003; 15(12):563-569. 39. Bryant-Lukosius D, Dicenso A, Browne G, Pinelli J. Advanced practice nursing roles: development, 2004; 48(5 ):519-529.

implementation

and evaluation. ) Adv Nurs

40. Cooperman JM, Riddle DL, Rothstein JM. Reliability and validity of judgments of the integrity of the anterior cruciate ligament of the knee using the Lachman's test. Phys Ther 1990; 70(4 ):225-233. 41. Oliver DR, Conboy JE, Donahue WJ, Daniels MA, McKelvey PA. Patients' satisfaction with physician assistant services. Physician Assist 1986; 10(7):51-60. 42. Benson CJ, Schreck RC, Underwood FB, Greathouse DG. The role of Army physical therapists as nonphysician health care providers who prescribe certain medications: observations and experien~es. Phys Ther 1995; 75(5 ):380-386. 43. Ayling Campos A, Graveline C, Ferguson JM, Lundon K, Schneider R, Laxer RM. The physical therapy practitioner: an expanded role for physical therapy in pediatric rheumatology. Physiotherapy Canada 2001; 53(4):282-287. 44. Ayling Campos A, Graveline C, Ferguson JM, Lundon K, Feldman 13M, Schneider R et al. The physical therapy practitioner (PTP) in pediatric rheumatology: high level of patient and parent satisfaction with services. Physiotherapy Canada 2002; 54:32-36. 45. DeBourgh GA. Champions for evidence-based practice: a critical role for advanced practice nurses. AACN Clin Issues 2001; 12(4):491-508.

AIKENANDMCColl, Taxonomy of Interprofessional Healthcare

Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

America/1 Journal of Pharmaceutical

INTERPROFESSIONAL

EDUCATION

Educatio/1 2009; 73 (4) Article 59.

SUPPLEMENT

Interprofessional Education: Definitions, Student Competencies, Guidelines for Implementation

and

Shauna M. Buring, PharmD,a Alok Bhushan, PhD,b Amy Broeseker, PhD,c Susan Conway, Wendy Duncan-Hewitt, PhD,e Laura Hansen, PharmD,f and Sarah Westberg, PhannDg

PharmD,d

"University of Cincinnati Winkle College of Pharmacy "College of Pharmacy, Idaho State University cSamford University McWhorter School of Pharmacy dCollege of Pharmacy, University of Oklahoma eSt. Louis College of Pharmacy fSchool of Pharmacy, University of Colorado Denver gColiege of Pharmacy, University of Minnesota Submitted October] 3, 200R; accepted April 9, 2009; published July 10, 2009. Interprofessional education (lPE) is an important step in advancing health professional education for many years and has been endorsed by the Institute of Medicine as a mechanism to improve the overall quality of health care. IPE has also become an area of focus for the American Association of Colleges of Pharmacy (AACP), with several groups, including these authors from the AACP Interprofessional Education Task Force, working on developing resources to promote and support IPE planning and development. This review provides background on the definition of IPE, evidence to support IPE, the need for IPE, student competencies and objectives for IPE, barriers to implementation of IPE, and elements critical for successfully implementing IPE. Kl~ywords: interprofessional education, competencies

INTRODUCTION Interprofessional education is an important pedagogical approach for preparing health professions students to provide patient care in a collaborative team environment. The appealing premise of IPE is that once health care professionals begin to work together in a collaborative manner, patient care wi II improve.I-4 Interprofessional teams enhance the quality of patient care, lower costs, decrease patients' length of stay, and reduce medical errors.s The World Health Organization,<' National Academics of Practice2, and the American Public Health Association7 arc a few of the many organizations that have articulated support ofIPE.s,x-lo Most notably, the Institute of Medicine (lOM) declared that "health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team ... ".s The 10M has clearly stated that patients received safer, high quality COlTcsponding Author: Shallna M. Buring, PharmD, Associate Professor, Division of Pharmacy Practice and Administrative Sciences, University of Cincinnati Winkle Collcge of Phannacy, 3225 Edcn Ave. Cincinnati, 011 452670004. Tcl: 513-558-8667. Fax: 513-558-4372. E-mail: sha una .buring@lIc.edu

care when health care professionals worked effectively in a team, communicated productively, and understood each other's roles.5 A Ithough there is an abundance o I'evidence supporting the IPE of health professions students, 11-19 this is not the n0l111 in most schools and colleges of pharmacy. This review of! PE presents definitions, provides supporting evidence, outl ines the need, proposes student competencies and objectives, summarizes the barriers to implementation, and defines elements critical for successful implementation. In 2005, the AACP Strategic Planning Committee met for a full day to discuss the issues and needs of AACP members with respect to IPE. The group reviewed current projects, identified opportunities for committee investigation, discussed the need for diverse models of IPE, and discussed opportunities for AACP program development. 20 The 2006-2007 Professional Affairs Committee Report stated they "accept the premise that teamdelivered care results in better health outcomes. The Committee therefore recommends that AACP endorse the competencies of the 10M for health professions education and advocates that all schools and colleges of pharmacy provide faculty and students meaningful opportunities to engage in IPE, practice and research to

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better meet health needs of society.,,21 Also in 20062007. the Academic Affairs Committee suggested in their report that schools and colleges of pharmacy "support and enhance IPE including interprofessional preceptor development.,,22 In 2007 at the AACP Annual Meeting, the AACP Section of Teachers of Pharmacy Practice recommended the Association "develop resources to assist faculty in promoting their IPE course and experiences at their schools and colleges. ,,23 Thus, AACP and many of its constituents have indicated that IPE is a priority in pharmacy education. In 2005-2006, AACP convened a Council of Facul-

relating how the professions would interact in an interprofessional manner of care; and • Participating in a patient care setting led by an individual from another profession without sharing of decision-making or responsibility for patient care.5•X•24 The goal of! PE is for students to learn how to function in an interprofessional team and carry this knowledge, skill, and value into their future practice, ultimately providing interprofessional patient care as part of a collaborative team and focused on improving patient outcomes. An interprofessional team is composed of members from different health professions who have specialized knowledge, skills, and abilities.s The goal of an interprofessional team is to provide patient-centered care in a collaborative manner. The team

ties Interprofessional Education Task Force with the charge of defining IPE, developing competencies in IPE, and identifying issues in implementing IPE in the various types of schools and colleges of pharmacy. This work was continued with the 2006-2007 Task Force iden-

establishes a common goal and using their individual expertise, works in concert to achieve that patient-centered goal.24 Team members synthesize their observations and profession-specific expertise to collaborate and communicate as a team for optimal patient care.5 In this model, joint decision making is valued and each team member is empowered to assume leadership on patient care issues appropriate to their expertise?4 Health care professionals from different disciplines who conduct individual assessments ofa patient and independently develop a treatment plans are not considered an interprofessional team. In this traditional model. the physician typically orders the services and coordinates the care and the lack of collaboration may contribute to an overlap and connict in care24

tifying common curricular themes for IPE and how to implement [PE in each of the varied types of schools and colleges environments. The 2007-2008 Task Force focused on identifying faculty development resources useful in promoting competency in IPI:, recommending means of implementing IPI:': and disseminating findings in a scholarly manner.

DEFINITION EDUCA nON

Education 2009; 73 (4) Article 59.

OF INTERPROFESSIONAL

Before engaging in the development and implementation oflPE at any institution, it is important to define the clements of IPE. Definitions of IPE arc varied and ubiquitous.x The Task Force expanded the Centre for the Advancement of Interprofessional Education (CAIPE) definition to read as follows:

EVIDENCE

TO SUPPORT

IPE

Interprofessional education involves educators and learners from 2 or more health professions and their foundational disciplines who jointly create and foster a collaborative learning environment. The goal of these efforts is to develop knowledge, skills and attitudes that result in interprofessional team behaviors and competence. Ideally, interprofessional education is incorporated throughout the entire curriculum in a verti-

Although an initial Cochrane review in 2000 found no studies which met inclusion criteria,25 a review in 2008 identified 6 studies evaluating the effcctivcness of IPE compared with traditional education on patient care outcomes and professional practice. Four of the studies showcd positive outcomcs on patient satisfaction. teamwork, crror rates, mental health competencies or care delivered to domestic violence victims, while thc other 2 found no impact on patient care or practice. Since there were a small number of studies with different interven-

cally and h~rizontally integrated fashion.5•R•24 It is important to also consider what is 1101 [PE. Examples of what IPE is not include: • Students from different health professions in a classroom receiving the same learning experience without reHective interaction among students fi'om the various professions3; • A faculty member {i'om a different profession leading a classroom learning experience without

tions, general conclusions could not be drawn. However, based on an interpretative approach to synthesizing the data, one can summarize that they were well received by participants, enabled students and practitioners to learn the knowledge and skills necessary for collaborative working, and can improve the delivery of services and make a positive impact on care.26 Another review article in 2007 included 21 articles evaluating I1>E; again, thcre were differences in the methodologies and outcomes of 2

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each study, and the results were provided in narrative manner. These studies illustrated positive reactions from learners, a positive change in perceptions and attitudes, and a positive change in knowledge and skills necessary for collaboration. Key mechanisms for effective [PE include principles of adult learning and staff development to improve group f~lcilitation.27 A systematic review by phannacy educators investigated the evidence of educational interventions in health professions to enhance learner outcomes related to interprofessional care. Upon review of 13 IPE training programs, positive results were seen in the knowledge domain when tested on other professions' roles and skills, interprofessional care, geriatrics, and quality improvement methods. Learners demonstrated positive results when measured on attitude toward other professions and health care teams. This review found minimal evidence

2009; 73 (4) Article 59.

PhannD program, with only 25%, of schools offering these courses in the first year?3 [nterprofessional education is, indeed, evolving slowing. Five years after the challenge from the 10M report, there has been minimal significant change in health professions education specifically designed to address the issue of IPE. However, there has been increased involvement from the health care community in this direction. The Institute for Healthcare Improvement Health Professions Education Collaborative was established to create exemplary learning and care models that promote the improvement of health care through both professionspeci fic and interprofessional learning experiences.34 In addition, there are a growing number of opportunities in interprofessional education conferences, such as the All Together Better Health Conferences, which are held biannually in locations around the world.35

for persistent behavior change related to group interactions, problem solving, and communications skills.28 The authors suggested that more controlled trials with objective outcome criteria are necessary.

NEED FOR INTERPROFESSIONAL EDUCA TlON In addition to the evidence supporting the value of IPE, various f~lctors have contributed to the need for IPE. These include a recent 10M report as well as accreditation standards and guidelines from several health care professions. The 2003 10M report" Health Professions Education: A Bridge to Quality" reOected discussion fI'om an interprofessional summit held the prior year involving 150 participants across many health care professions. The resulting 5 core competeneies that should be common in health professions' education were imbedded in the following vision statement from the summit: "All health professionals should be educated to deliver patientcentered care as members of an interprofessional team, emphasizing evidence-based practiee, quality improvement approaches, and informatics.,,5 This report has served as a major impetus for health care professional and educational organizations to move forward in meeting the need for IPE. Aecreditation standards and guidelines from health care professions have also addressed the necessity for this collaborative approach in education. The Accreditation Council for Pharmacy Education (ACPE) created standards and guidelines effective since July 2007 that delineate the desire for WE. Guidelines lA, 6.2, 9.1, and several areas in Standard 12 clearly engage interprofessional learning, practice, activities, and patient care. Specifically, Guideline 104 asserts that "the college or school's values should include a stated commitment to

Evolution of Intcrprofcssional Education The need 1'01' [PE has been recognized internationally since the mid [980s. In the United Kingdom, the Center for the Advancement of Interprofessional Professional Education (CAIPE) 8 was established in 1987, and The Journal/or Illfelprr?!essional Care was first published in 1986. In Canada, the Interprofessional Education for Collaborative Patient-Centered Practice Initiative was begun by IIealth Canada in 2003.29 Traditionally, individual health professions have been trained primarily in their own schools or colleges by members of the same profession. Traditionally, firstthrough third-year pharmacy students have been taught in classrooms only with other pharmacy students. For many students, their first exposure to IPE does not occur until they reach their advaneed pharmacy practice experiences (APPEs) in the fourth year. There are exceptions in specific institutions or specific cases where [PE has been integrated earlier into the curriculum,17,30-32 but this is not yet the standard in pharmacy education. [n 2007, faculty members from the St. Louis College of Pharmacy conducted a survey of schools and colleges of pharmacy regarding [PE. Of the 31 schools responding to the survey, 47% were not currently offering IPE. Information on interprofessional offerings at the schools not responding are unknown, but their lack of response may indicate an even higher percentage of total programs not offering [PE. Of the schools and colleges offering IPE, the authors found that more than 60% orthe interprofessional courses were offered in the third or fourth year of the

a culture that, in general, respects and promotes development of interprofessional learning and collaborative practice"; Guideline 6.2 states that "the relationships,

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collaborations. and partnerships collectively should promote integrated and synergistic interprofessional and interdisciplinary activities"; and Guidel ine 9.1 affirms that "the college or school must ensure that the cUITiculum addrcsses ... competencies needed to work as a member of . {'. I team. ,,16 or on an ll1terprolesslOna Concerning medical education, the Liaison Commit-

Educatio/1 2009; 73 (4) Article 59. preparation of the graduate to function effectively and efficiently in multiple health care environments within interprofessional health care teams ... including consultation and referral. ,,40 Lastly, the Association of Schools of Allied Health Professions chose for its 2()06 Annual Conference the theme of" Framing Interprofessional Education, Practice. and Research: Preparing Allied Health Professionals for the 21 st Century" .41 Although accreditation standards for each of the allied health professions will not be discussed individually at this juncture, it is intriguing to know that IPE is a major focus of this professional organization. As other health professions accrediting bodies move to include IPE in their standards. this will serve as an addi-

tee on Medical Education (LCME) is the accrediting body for medical schools in the United States and Canada. Currently, there arc no official accreditation standards about (PI:: speci fical Iy in medical education. However. Standards ED-19 and ED-23 reteI' to interacting with other health care providers and state that "there must be specific instruction in communication skills as they relate to physician responsibilities. including communication with patients. families, colleagues, and other health professionals. A medical school must teach medical ethics and human values, and

tional incentive for the profession overcome barriers in (PE.

to work together

As mentioned earlier, the 10M report developed core competencies for health professions education including "work in interdisciplinary teams: cooperate. collaborate. communicate, and integrate care in teams to ensure that care is continuous and reliable. ,,5 In conjunction with these core 10M competencies, the 2006-2007 Task Force developed student competencies achievable through IPE. Task Force members reviewed pertinent IPE literature.I,3,8.24 brainstormed potential competencies. and used a consensus approach to develop the tinal list of competencies. Each competency has specil1c objectives that help build toward the overarching competency. The Task Force recommends that these competencies be achieved through inteq)rofessional education: team organization and function, assessing and enhancing team perf01l11ance. intrateam communication, leadership, resolving conflict and consensus building, and setting common patient care goals. Many of the competencies proposed far IPE relate to teamwork. Sharing information about the roles of team members. determining professional responsibilities and boundaries. and learning about how different professions can work together to optimize their strengths in providing patient care all contribute to the development of professionals working together towards a common goal (eg, optimizing patient care). Communication is a key skill in effective team functioning; the ability to use communication techniques to enhance team functioning and deal with barriers that interfere with communication is neces-

require its students to exhibit scrupulous ethical principles in caring for patients, and in relating to patients' tiunilies and to others involved in patient care.,,37 The Commission on Collegiate Nursing Education is the accrediting agency for baccalaureate and graduate nursing programs in the United States and works closely with the American Association of Colleges of Nursing (AACN). The Essentials of Baccalaureate Education for Pr(~lessional Nursing Practice contains the accepted standards for baccalaureate programs in nursing and was recently revised in 2()08. Essential VI (lnterprofessional Communication and Collaboration for Improving Patient lIealth Outcomes) focuses on IPE as a central competency for patient-centered care. Part of the document states that "interprofessional education enables the baccalaureate graduate to enter the workplace with baseline competencies and conl1dence for interactions and communication skills, that will improve practice. thus yielding bettcr patient outcomes .. " intcrprofessional education optimizes opportunities for the development of respect and trust for othcr members of the health care team. ,dX This standard also includes examples of integrative strategies for learning through IPE. such as course assignments, simulation laboratories. and community projects. The Commission on Dental Accreditation has outlined standards for both general and advanced education programs in dentistry. General dentistry Standard 1-8 states that "the dental school must show evidence of in-

sary for optimal teamwork. Understanding how to assess team performance and use that data to improve team members' skills and modi fy roles to enhance performance is an important competency in IPE. Leadership can be an important competency for interprofessional education and leaming how to effectively facilitate an interprofessional tcam mecting is onc important objcctive. Objectives related to conflict resolution and consensus building arc

teraction with other components of the higher education. health care education and/or health care delivery systems. ,,39 Additionally. even though the standards for advanced education programs in dentistry do not address IPE specifically, there is mention of interprofessional teamwork and interacting with other health care professionals: "the goals of these programs should include

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essential to building an effective interprofessional team player. Learning how to identify and address the origin of team problems and implement strategies for overcoming these issues are objectives that build toward competence in resolving conflict. Working together to set common patient care goals may be considered a terminal competency for interprofessional education. The ability to identify and achieve a common patient care goal as an interprofessional team oflearners could be considered the ultimate goal for IPE. Table I includes a list of specific . eac I1 competency area l'or 1PI':.'-"1 3 H 24 o b" .Iectlves wit. I1111

BARRIERS

and commitment can negatively tion of I PE.43 Barriers at the administrative

TO IMPLEMENTATION

1 PE were scheduling, rigid curriculum, "turfbattles," and lack of perceived value to IPE.42 Attitudinal differences in health professionals, faculty members, and students also influence implementation ofIPE. A lack of resources

affect the implementalevel are multifactorial,

including the perception of whether it is worthwhile to direct resources to a new change given the demands of the other missions of an institution. It is important that administrators understand and f~lcilitate the need for changing the education and training of professionals as health care changes. In addition, logistical concerns such as scheduling and space may need to be overcome at the administrative level to advance a longterm commitment to (PE. faculty members will also need to appreciate the advantages of IPE so that they can be fully engaged in implementing the change. Faculty members may be resistant to changes due to increased workload and lack of time. Leaders in the professional field have a responsibility to motivate faculty members to make these changes and have a system to reward faculty members for their efforts 11>E. Operations manin developing and implementing agement of the education system in many professions will need to be altered to align the curricula to one another.

Barriers to initiating IPE can be encountered at various levels of the organization including among the administration, f~ICUltymembers, and students. A study of Canadian schools identified that the main barriers of

Table

2009; 73 (4) Article 59.

Student Competencies and Objectives for Interprofessional

Educationl..1路8,24

Team Organization/runction Explain your role and the roles of other team members. Determine professional responsibil ities, roles and boundaries. Determine critical team rules about: a) purpose; b) composition; c) attendance; d) case management system/process; e) team development. Determine alignment among different professions and settings of care to make optimal use of intellectual, physical and sociobehavioral skills. and their overlap. Dclineate procedures and processes for seamless documentation of patient-centered care. Determine the financial aspects of functioning in an interprofessional team for patient care. Assess and Enhance Team Performance Routinely assess the performance of an interprofessional team collaboratively and individually. Roulinely assess individual interprofessionalleam member perf0I111anCethrough self and peer assessment. Modify the team's performance and roles accordingly to enhance interprofessional performance, Identify deficient individual and team skills whose development would serve to improve team performance. Intrateam Communication Choose effective communication tools and techniques that enhance team function. Identify and overcome barriers that interfere with the quality of communication within the interprofessional team. Leadership racilitate an effective team meeting that incorporates at least the following: 1) clarify objectives; 2) determine team roles; 3) review tasks; 4) complete tasks: 5) document task completion and consensus on team decisions; 6) plan next steps; 7) assess meeting. Assume or delegate the role of providing team socio-emotional support (team mediator) to sustain the cultur~ of the team. Assume and relinquish goal-oriented leadership appropriate to one's expertise and the stage of patient care needed. Resolving Conflict and Consensus Building Identify and address organizational, institutional and health care systems issues that give rise to team problems. Identify and address the origins of team problems within the team. Identify, discuss, choose and implement strategies for managing and overcoming an interprofessional team conflict. Setting Common Patient Care Goals Identify and achieve a common patient-centered care goal. Assess, plan and implement effective, emeient and seamless care collaboratively. 5

American Journal of Plllirmaceutical Education 2009; 73 (4) Article 59. This includes the physical space as well as course design and scheduling. Ideally, the physical space of schools and colleges should be adaptable to IPE. This may require modification of current structures of schools, and IPE

unknown batTiers that were not anticipated during the original planning efforts. Professional organizations such as AACP, Accreditation Council for Pharmacy Education (ACPE), American College of Clinical Pharmacy (ACCP), American PhaI111acists Association (APhA), American Society of Health-Systems Pharmacists (ASHP), should work on a similar platform to overcome these barriers. A mutual collaboration of different health delivery professions will be needed to promote and implement IPE. All stakeholders, even in an individual profession and involved in education (as mentioned above) should come together for a better outcome of IPE.

should be considered when new schools are being designed and built. Another barrier in implementation is the logistical challenge of synchronizing classes among di fferent health professions so that students can physically be together to learn. It may be difficult to find common times for IPE courses and avai lable classrooms large enough to accommodate the increased numbers of students. Also, even if a university has multiple health professions schools, they may not be in close proximity to one another. This may require allocating resources to develop multi-professional laboratories and classrooms for IPE. The 10M report states that education should not occur in a vacuum, and a "hidden curriculum" exists. "This' hid-

ELEMENTS CRITICAL TO THE DEVELOPMENT OF IPE Regardless of the health care professions involved or location of the college or school. we purport that there are basic tenets of implementing IPE that, if followed, will help establish a successful IPE experience. The AACP Task Force on Interprofessional Education members used key IPE resources and professional experience with IPE to develop this list of steps essential in the process ofIPE development. Personnel and financial resources as well as administrative and faculty time are essential for successful implementation ofIPE. Thus, IPE should be identified as a goal of the curriculum or as part of the strategic plan. Those members of the f~lCUlty and administration who champion IPE need to lead and support IPE initiatives. It is necessary to cultivate relationships with other health care programs based on geographic location, existing relationships, etc. Administrative and faculty champions in the partnering programs need to be identi fied. Once an IPE planning team has been established, the team should identify appropriate IPE curricular themes and decide which students from each program should be involved based on equivalent levels of education. The team should determine when and where the IPE curriculum will occur

den curriculum' o I'observed f~lculty or cl inician behavior, informal interactions and conversations with fellow students and with faculty and practicing professionals, and the overall norms and cultures of the training or practice environment is extremely powerful in shaping the values and attitudes of future health professionals.,,5 The fact that many health care settings have not yet fully implemented interprofessional team care can be a barrier for IPE. Students may struggle with the application, or may not see the necessity of the team skills they learn during IPE. It is necessary to instill in students the importance of IPE to promote future change in the profession of pharmacy and in the overall health care system. University environments ditTer considerably with respect to presence of di fferent combinations of health professional schools within the universities or their surroundings. This will create another level of challenge. The design ofa standardized curriculum for IPE that will include di fferent professional schools is dependent on a variety of issues. IPE should be implemented in the basic, foundational courses.44 Developing these bridges between professions in basic courses may lay a foundation that will establish the tencts of inter professional team care throughout the training period. Assessing the outcome of lPE is particularly important give the resources comm itted to IPE. A systems approach for the centralized assessment of the health professional's outcome may become necessary. This will require all stakeholders to devise consistent evaluation tools and methods. Multidisciplinary development of the outcomes assessment process necessitates time and resource commitment from all of the health professions involved.

and who will facilitate the curriculum. A gradual implementation ofIPE with the motto "start small and go slow" is advocated so that some successes can be realized and modifications can be made with each iteration of the IPE curriculum. Development programs to ~upport faculty teaching in IPE are encouraged as are recognition programs for faculty members involved in IPE. An assessment strategy to evaluate the IPE initiative should be planned, as wcll. Critical clements for implementing IPE are listed in Table 2.3A5.4()

CONCLUSION The definition of IPE as developed by the Task Force may serve as a guide to educators beginning the process of IPE developmcnt. Thcre is considerable evidence to

The process of implementing a new culture and cultural changes may indeed surprise the stakeholders with

Americall Journal Table

2. Elements

Critical

(~lP/wrmaceutical

for Implementing

Interprofessional

• Identify interprofessional education (JPE) as a goal of • Identify administrative and faculty champions at your - Commit the time, personnel. and financial resources • Establish relationships with other health care programs, existing relationships.

Educatioll 2009; 73 (4) Article 59.

Education3As•4<>

your college/school of pharmacy. college/school to lead and support IPE initiatives. necessary for success. considering geographical location, university ownership/affiliation,

and

- Schools/colleges of pharmacy without other health profession programs at their institution can still accomplish effective partnering with other institutions of higher education that mayor may not be within the geographical area. • Identify the administrative and faculty champions at each of the partnering programs. • Establish an IrE planning team with engagement from every player. - Choose IPE curricular themes. - Evaluate equivalent levels of education; match students based on education level and maturity. - Determine when and where this IPE will occur in the curricular schedule and who will teach/facilitate curriculum.

IPE by

the interprofessional

- Gradually implement based on level of preparedness (start small and go slow). - lPE planning team members must advocate for the acceptance of IPE curriculum at their individual schools/colleges. • Offer (~lcIIlty development programs to support faculty teaching in IrE. • Establish faculty rewards and recognition for IPE involvement. • Determine an assessment strategy to evaluate the IrE initiative and share results with internal and external stakeholders as well as the academic community via scholarship.

support IPE and certainly the accreditation standards for pharmacy may be considered one impetus. As with any educational curriculum, IPE ideally would faster specific competencies in the learner, including teamwork, leadership, consensus building, and the ability to identify and achieve common patient care goals. Although there are barriers to IPE, including logistical and resource issues, we advocate developing a plan for IPE that includes key elements critical for optimal success.

ACKNOWLEDGEM The authors

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Health

policyscarch/dcfaull.htm'!id=

chaired the 2006-2007 AACP Task Force. Special thanks to Tim Tracy who chaired the inaugural Task Force in 2005-2006 and Gayle Brazeau, Task Force mcmber in 2007-2008.

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Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.

.•

••.•.......

•

@WILEY

l11terSciel1Ce" D I S C 0 V I II

S Ow

H lit

G ~ f AT

Foundations of Continuing Education

Theories to Aid Understanding and Implementation of Interprofessional Education

PHD

JOAN SARGEANT,

Multiple events are calling for greater interprofessional collaboration and communication, including initiatives aimed at enhancing patient safety and preventing medical errors. Education is 1 way to increase collaboration and communication, and is an explicit goal of interprofessional education (lPE). Yet health professionals to date are largely educated in isolation. IPE differs from most traditional continuing education in that knowledge is largely socially created through interactions with others and involves unique collaborative skills and attitudes. It requires thinking differently about what constitutes teaching and learning. The article draws upon a small number of social and learning theories to explain the rationale for IPE needing a new way of thinking, and proposes approaches to guide development and implementation of IP continuing education. Social psychology and complexity theory explain the influence of the dynamism and interaction of internal (cognitive) and external (environmental) factors upon learning and set the stage for IPE. Theories related to professionalism and stereotyping, communities of practice, reflective learning, and transformative learning appear central to IPE and guide specific educational interventions. In sum, IPE requires CE to adopt new content, recognize new knowledge, and use new approaches for learning; we are now in a different place. Key Words: interprofessional stereotyping, professionalism.

education, theory, social psychology, reflection, transformative learning

Introduction Multiple factors contribute to the growing interest in interprofessional education. team-based patient care. and collabonJtive practice. The patient-safety literature reports that most medical errors are avoidable and many can be prevented by enhancing communication and collaboration among health professionals. I An increasing number of patients are living with chronic disease and their care is often beyond the scope of a singe physician or other health care professional. Because of increasing complexity of care. physicians frequently arc no longer able to meet the diversity of their patients' needs on their own.2..1 Tnlditional models of health care in which

professions

Disclosures:

and dcpartments

The aUlhor

Or. SlIIgca/ll:

Director

reports

Halifax.

of Research

Nova

Scotia.

Corr,'Spondence:

.loan Sargeant.

Research

Room

Centre.

enue. Halifax.

o 20119 The Academic Association InlerSeience

CIlI6,

Nova Scotia Alliance

Continuing

and

for Hospital

Evalualion.

Continning Dalhousie

Medical

e-mail:

Medical

Education

Educalion,

University.

5849

and .•

EDUCATION

the

Av-

the Society

Council

Puhlished

DOl:

Clinical

University

joan.sargeant@dal.ca.

Education.

(www.inlerscience.wiley.colll).

JOURNAL OF CONTINUING

Cominuing

Canada.

for Continuing Medical

or less

Director. Program of Research in of Medical Education. Dalhousie

IBH 4H7. Canada;

Medical

morc

none.

Education and Associate Professor and lIealth and Medical Education. Division University.

practice

online

for

CME,

in Wiley

10.1 002/chp.20033

complexity

theory, communities

of practice,

in silos can increase patient risk and reduce quality of care. J-1 Similar to professional practice. health professionals are traditionally educated in silos at undergraduate. postgraduate. and continuing education levels. It seems that in this way education is perpetuating the isolation of professions. Continuation of the old ways of separate professional education will probably not lead to improved interprofcssional collaboration and practice. It is proposed that achieving improvement will take a transformation in our way of thinking and educating. not just a tweaking around the edges of what we are now doi ng. Understanding the need for a transformation requires a look at what interprofessional collaboration and education entail. The goal of interprofessional education (lPE) is "collaborative practice. to engage professionals in learning how to work together by providing the knowledge. skills and attitudes required to effectively collaborate,'·4.5 Inchcators of successful collaborative practice include demonstnning respect for other professions. understanding their roles. communicating clearly and effectively. resolving conflict effectively. and sharing common goals.2 .., IPE occurs "when members of two or more professions learn with. from. and about one another" to improve collaboration and patient care.1> Although health professionals may now occasionally formally learn "with" each other in groups. ego learn in parallel about a new clinical intervention. they more

rarely learn "from" and "about" each other:I-6

IN THE HEALTH PROFESSIONS.

29(3):178-184,

2009

Theories to Aid Understanding

and Implementation

af Interprafessional

Appreciating that !PE differs in content and process from much of traditional continuing education (CE) is central

and strives

to its successful implementation. CE has cused upon the top-down transmission of ily clinical knowledge, from an expert to expertise. In contrast, a significant focus

chology are particularly app]icable when considering interprofessional education. The first is that situational factors exert powerful influences upon behavior. Studies show that even subtle changes in the social setting or environment (eg. the mood of a particular team member) can be more influential of behavior than individual. and supposedly stable, personality traits. The second principle is that it is not just the influence of socia] factors upon behavior, but also the subjective individual interpretations of the situation that influence behavior. For example, how do team members individually interpret the mood of another and respond to this interpretation? The third principle shows that both the social system and environment, and individual cognitive processes. are dynamic and interact dynamically; ie, nothing is constant (see FIGURE I). Interactions arc complex and out-

traditionally 1'0content. pri marothers with less of IPE is learn-

ing "from" and "about" each other; ie. knowledge is large]y created through the social exchange and interactions of different professionals. Such learning occurs both in structured activities and informal]y through interproressional interactions and work in practice settings.? The focus of ]PE is equally upon the learning process as it is upon content. Content includes distinct knowledge, skills, and attitudes and each domain is equally important. Unique features of IPE include explicit strategies to build awareness of and respect for professional perspectives and roles that differ from one's own, and to develop specific interpersonal skills 1'01' efrective collaboration and communication.2-6 The unique elements of IPE highlight its significant differences in philosophical premise, content, and format from much of traditional CE.? Because

to determine

Education

more accurately

predicted.

if and how human Three contributions

behavior

can be

or social psy-

comes are not predictable; what happens at ] time may not happen at the next. For example, the subtle influences of the mood of I team member upon learning will vary depending on other factors.

of these differences. [PE takes us to a different place in professional education. While adult learning principles can inform IPE as they have CEo they alone are insufficient to guide its deve]opment and imp]ementation.u IPE is built on social and ex-

For continuing education generally this means we cannot predict how learning will be interpreted and integrated into individual contexts. For interprofessional education and rractice in particular. implications include:

periential learning, and theoretical perspectives that inform these phenomena are needed.'! This article draws upon social and learning theories that seem most applicable to

I. Participating in and learning from IPE is influenced by illdividual internal factors and external environmental factors

continuing [PE in this. its early stage of developmenl.?路'! The article has 2 main goals-to more fully explain the rationale for interprofessional education taking us to a different place and needing a new way of thinking. and from this foundation. to propose approaches to guide deve]opment and implementation of interprofessional continuing education.

Theoretical Perspectives: Way of Thinking

PSYc/IO/Ogv,

Social psychology

1).

., Health professionals allendi ng the same educational event can see it through very difTerenl eyes. both individually and professionally. 3. Individual workplace factors influence the ability to integrate Ilew learning into practice. 4. Continuing IPE needs to be attentive and responsive to these situatiolls.

Complexily Theory

Belta\'ior, and Learning explores

but not limited to. other members of the team

(PIGURE

Rationale for a New

An array of learning and related theories can contribute to understanding and implementation of IPE:'I one approach particularly pertinent to CE links continuous quality improvement and CE within the framework of social learning.lo However, 2 theoretical perspect ives are especially useful in understanding the rationale for needing to think differently about !PE. These are socia] psychology and complexity theory.l.'!.11 which recognize the social and experientia] nature of interprofessional learning and the complex health care environment in which it takes place.

Social

including,

the interaction

between

individ-

ua]s and their life situations or contexts.12 Specifically. it considers the influence of situational factors upon behavior JOURNAL

OF CONTINUING

Health care is a complex system. and complexity theory refers to systems behavior and systems c1lange.II.I.1.14 Comp]ex systems are comprised of many components that are dynamic and continuously interact. These interactions are more important than discrete actions or individuals or components. IS Complexity theory encourages us to look at continuing professional education differently as it moves the focus from the individual professional and how he or she learns and changes in response to education. to the health team, health system. and environment. Complexity theory also moves us from a reductionist or Iinear view of education and practice. which overlooks the interaction of individual elements and considers processes value-free: ie. personaf and social influences did not intervene. IS The main features of complexity theory include the following: EDUCATION

IN THE HEALTH PROFESSIONS-29(3), 2009 DOl: 10.1 002/chp

179

TeamI

.--~

\ t~ +--intervention I

Educational

.,1

Sargeant

,,'

II I

FIGURE

I. Social

psychology:

interaction

I. Complex systems consist of multiple components and are understood by observing the interaction of tbe components. 2. Interaction among components can produce unpredictable behavior.

J. Complex systems interact with and are inOuenced by the environment. 4. Interactions between components of' the system arc nonlinear: ie, the results of' any action depend upon the state of' the components at the time. S. Interactions generate new properties, rcrerred to as emergenT behlll'iors.

6. Such emergent behavior cannot be predicted. To help us understand interprofessional education as a complex activity, D'Amour and Oandasan t6 have dcveloped a conceptual model linking interprofessional education and practice. It illustrates the multiplicity of interactions and relationships among individual learners and practitioners: teams: education; and health systems and organizations, environments and cultures, all of which influence what is learned and what is applied in practice. All require consideration in developing and implementing IPE. Spccific implications of complexity theory for continuing IrE include: I. Realizing that IrE is complex and not a simple undertaking is belpful. It encourages us to be thoughtful and careful as we move ahead. 2. Understanding and being responsive to the practice setting within which intcrprofessional tcams arc working arc critical to success. IPE docs not take place in a vacuum. J. Interprofessional practice and education are interrelated. Because IrE occurs through social exchange environments, social psychology and complexity 180

JOURNAL OF CONTINUING 001: 10.1002/chp

EDUCATION

Pmctico context

in complex theory pro-

of self.

team.

and cnvironmenl.

vide rationale for an expanded vision of continuing education to accommodate IPE. Now we move, in the next section, to theories that propose specific approaches to learning and teaching IrE. Although there are many to consider,9 4 arc included in the section below: social theories explaining social identity, prorcssional ism, and stereotyping; communities of practice; retlective learning: and transforrnative learning. Each was specifically chosen. Building on social psychology and complexity theory, the first informs approaches to learning within a social context, especially attitudinal learning which is frequently critical to IrE. Communities of practice addresses social and experiential learning in a dynamic and complex environment characteristic of interprofessional practice. Reflective learning theories explore how professionals might individually learn from their interprofessional experiences and education. Finally, seeing IPE as transformative learning enables better appreciation of the need for a new way of thinking and knowing.

Theoretical Perspectives to Guide Development and Implementation of Interprofessional Continuing Education Theories Explaining ({1ll1Stereotyping

5;ocilllldentity,

Prr!!eS.I'iOlla!islIl.

Allport, a social psychologist conducting much of the original work on effective group interactions, proposed that "contact was not enough" to build collaboration among different group members.17 Having members from different backgrounds just learning "with" each other was inadequate to build the trust, respect,

IN THE HEALTH PROFESSIONS-29(3),

2009

and effective

communication

needed

Theories to Aid Understanding

for collaboration

and teamwork.17.JH One explanation

and Implementation

for this

is the concept of social identity, the recognition that one belongs to a certain social group and the emotional and value significance of that membership.JH.,<) Social identity contributes to how individuals see and relate to others. It gives the sense of being part of a distinct "in-group" and builds positive feelings and self-esteem. Shared values contribute to social identity and are strong tics that bind professionals into their respective groups. Working collaboratively can mean giving up valued social identity. Freidson's work moves beyond social identity and explores professional ism. A profession is a speci fically socialized and educated group that controls its own work. holds shared goals and values. and is committed to doing the work well and gaining approval and respect of colleagues .. Health professionals are socialized into their respective professions. A barrier to achieving IPE and collaborative practice is the strength of competing individual professional identities. scts of values. and cultures.H :!11

Social categorization is another internal process influencing how individuals respond to each other. It is used to reduce the complexity of information of our social world by creating mental shortcuts. These are essential to daily living but cause us to overlook individual charm:teristics.21 The disadvantage is that holding established reotypical views of fessional education

mental shortcuts lead to stereotyping, to views that are resistant to change. Steother professions can impede interproand collaboration. IH

Whitehead draws upon perspectives of social identity. professionalism, and stereotyping to describe how medical students are educated to fulfill the roles and expectations of their profession, and why this is problematic for IPE.22 In North America the medical profession holds a place of privilege. Medical status is a stereotyped approval that is socially developed and held and therefore difficult to change. Medical education is a process of identity development, a taking on of this status. Within it. medical students are traditionally socialized to take on the role of leader and decision maker. However, it creates a conundrum for interprofessional practice and education, as interprofessional collaboration requires flexibility and a sharing of leadership and decision making in response to patient needs. If other professions take on more leadership and decision making and the status conveyed by it. physicians may percei ve that they are losing status. Yet the education system does not prepare them for this change. Implications of theories of social identity, stereotyping, and professionalism for IPE include:

IrE of necessity must include recognition and exploration of the strong influence of one's own professional iuentity anu culture. and of stereotypes held by health professionals of other professions. upon collaborative learning and practice. ') It must also include discussion and exploration of the shifts in traditional power structures and decision-making models required ror collaborative practice. I.

JOURNAL

OF CONTINUING

of Interprofessional

Education

3. Specific interventions to balance the competing tensions of valuing one's own professional role while developing more collaborative ways of practicing are essential components of IrE. For example, an effective strategy can be to view the patient as the center of the team and provide collaborative patient-centered care that meets the patient's needs-the goal. Focusing on the patient can reduce the rocus on self as professional.2:\

Siluated Learning and Communities (~rPractice Situated learning24 and communitics of practice25.26 are 2 related social learning approaches. Situated learning views learning as a social activity situated within a particular environment or context (eg. a health care team)?! Learning takes place through interpersonal interaction and interaction with the culture and environment. There are 2 essential premises: ( I) context strongly influences what is learned and (2) learning takes place through interaction or <'coparticipation.'路 Both components are also critical elements of IrE. Building on the concepts of situated learning. communities of practice are described as "groups or people informally bound together by shared expertise and passion for a joint enterprise.',27 They can he, for example, groups of health professionals caring for patients with particular health needs. In communities of practice, practitioners work together and, through their work and experiences, learn and collaboratively create new knowledge. Learning is not a discrete activity separate from work and practice, it is integral to it. Both occur at once. Conceptually, communities of practice require us to rethink how we envision teaching and learning. Much information exchanged in communities or practice is formal knowledge such as practice guidelines, protocols, and patient records. But in health care, as in many occupations. informal or tacit knowledge is equally valuahle, ego the process knowledge of how to get things don~.26 For IPE. traditionally tacit knowledge in health care and educationabout the processes of collahoration such as how to work as a team. what each member contributes, how to make decisions-becomes the focus of learning, the new formal knowledge.2s Generally speaking. this means a new way of thinking for educators. including both recognition of a new type of knowledge and of a new format for learning. communities of practice. A strength of communities of practice is that they can readily share tacit knowledge through interaction, stories. observation. and working together, and build on it to enhance their collaborative practice. Importantly, communi路 ties of practice are built on mutual respect and offer a safe learning environment, necessary criteria for effective IrE. A limitation is that they often require a leader or facilitator to guide the learning process, ie, a professional skilled in facilitating interaction and learning from each other. Implications for situated learning and communities of practice for continuing IPE include: EDUCATION

IN THE HEALTH PROFESSIONS-29(3), 2009 DOl: 10.1 002/chp

181

Sargeant

I. Foster situated practice-based learning in naturally occurring II' teams. 2. Support the learning of tacit process knowledge. 3. As CE professionals. become prepared to take on a new role. a role of supporting a community of practice and facilitating. as needed. their learning from and about each other and sharing tacit knowledge. 4. This may mean we need to go to the practitioners, not vice versa as is traditional.

Re.flective Leamil/R and Leamil/R

From EI'fJeriel/(,(,

In the previous section we considered IPE as social learning, but how do individuals individually learn from interprofessional practice and experience? Schijn's model for educating the "reflective practitioner" reminds us that health professionals need to be well prepared in the science of their work but also in dealing with the "gray" areas where uncertainty and value conflicts are more commonplace.2'! Interprofessional practice can be one of those gray and value-laden areas. and learning through one's with others are desired

being reflective own experiences characteristics.7

and open to new and interactions

Critically reflecting upon experience appears eenlral to learning. It appears to function as a mediator between existing knowledge. skills. beliefs and values. and experience.]O But the process is often nol explicit and it may be most useful when viewed as a learning strategyÂˇ~1 and often requires f~lcilitation.J2 Boud et al describe a 3-step model of reflection as a way to learn from experienceJO The first step is returning to the experience, to clarify in one's mind the events. acknowledge feelings at the time. and consider different perspectives. The second is attending to feelings. both positive and negative, and understanding how feelings influence response to the situation and subsequent actions. Attending to feelings related to an experience is critical to learning from it successfully. The third step is re-evaluating the experience. Often individuals skip steps I and 2 and hence operate at step 3 on false assumptions. Step 3 includes relating new data, integrating it. validating it. and finally making it one's own. Baud et al stress that the steps of reflection can be taught, and that reflecting on one's own can often be ineffective; a knowledgeable facilitator is invaluable. Implications of reflective continuing IPE include:

and experiential

learning

I. Formally incorporate reflection upon what individuals and the group arc learning about their colleagues in other professions. and about collaboration and teamwork. into learning activities. 2. Recognize that reflecting honestly upon feelings is an oftenoverlooked but necessary step for learning. Learning about the roles of others and the need to collaborate can evoke emotional reactions. ego a sense of loss. 3. Be prepared to facilitate the reflective steps and to help professionals learn through rcl'leetion from their experiences. 182

JOURNAL OF CONTINUING 001: 10.1002/chp

EDUCATION

for

7i'l1l1s(orl1lotive Lel1rninR, Not .Illst TinkerillR Around

the Edges Transformative see ourselves.

learning is learning that changes the way we those around us, and the world.]] It is not

simply learning new knowledge or skills or extending what we already know into a new topic or domain. [t actually changes "what we know" (Kegan, p. 48).J4 Transformative learning is based on 3 fundamental activities: learning from experience, critical reflection. and personal development. In learning from experience, experiences can he planned or unplanned and can involve individuals in various ways; ego cognitively, physically, emotionally. If and how individuals learn from that experience is influenced by their own world view, values, and heliefs. Experience may trigger learning for some and not for others. It is suggested

that trans formative

learni ng occurs when

one cannot easily fit a new experience into their existing knowledge, views, or perspectives. Such a situation stimulates reflection. Critical reflection is a cognitive process by which individuals qucstion existing knowledge and importantly, underlying beliefs and assumptions. including those related to power distrihution, and strive to make sense of a new experience. Frequently this process elicits emotional responses.35 It is the re-examining of long-held bel iefs and values that leads to transformalive learning.JI1 Achieved through the processes of experience and critical reflection. the intended outcome of transformative learning is indi vidual consistent with sonal growth.:n with others, and

development. Learning as development is humanist theories of learning and of perNew ways of seeing the world, interacting approaching problems can result.

Implications include:

of transforrnative

learning for continuing

IPE

I. II'E requires a recognition of a new type of knowledge: it changes "what we know." Knowledge traditionally valued and included in CE programs has been clinical content. Knowledge valued in II'E is process knowledge. how health professionals work together. how teams interact and communicate effectively. how to demonstrate respect for the roles of others.2â&#x20AC;˘3 2. It also requires

recognition of learning in different ways. through interactions with others. the environment. reflection on these experiences and IVorking collaboratively to create new learning7 3. Such learning also challenges values and assumptions. among them how health professionals see themselves and others as members of a team. It is not value-free: it is orten sensitive

work.:u

Summary In summary, the goals of this article were twofold-to use theory to first explain the rationale for interprofessional education needing a new way of thinking. and then propose approaches to guide developmcnt and implementation of

IN THE HEALTH PROFESSIONS-29(3),

2009

Theories to Aid Understanding

and Implementation

Lessons for Practice

of Interprofessional

lIaml11ick

M, Freeth

systenwtie

review

Med rellch. 7. Clark

• IPE is learning about how to work together and the roles of others; it is a new curriculum for CEo • Social theories of learning demonstrate that the IPE curriculum is best learned through interaction and collaborative knowledge creation.

• Reflection upon learning and practice is integral to IPE.

matteo

D. A scoping

Grol

rclevant PM.

Janes

in health

ent way and changes what we know and value as knowledge and professional practice. Seeing continuing IPE as transformative learning forces us to recognize that we are in a differcnt place and we need to think differcntly.

dl/clirl/J.

Mil/bank

Ihe 21sT Celllllry.

Washington.

K. Bodenheimer

C!/(/Slll: 1\ New Heallh

DC:

H. Koppel

fJroJi'ssiollal

T. Cau health

J :111IMed Asso,., 2004:29

care practice"

Ihe Qilalin'

Carpenter

National

Academy

Press:

and

I. Reeves

EdllcaTioll:

United

Kingdom:

lIarden

RM. AMEE

S. Hammick

AlglllJlelll.

Blackwell:

and

Kingdom:

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Part

learner.

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improve

M. Freeth

A.HlIml,'irll/

D. I:[{ecliw'

& /;·,·idellce. London.

guide no. 12: Multiprofessional

S. Key clements the educator

education:

A three-dimensional

of'l'l'l:il/{lice.

Chicago,

IL: University Cambridge

Whitehead

C. The

lIeadrick

I.ave.l,

for interprofessional

LA,

doctor

and the learning

context.

J Inlal'rur

York,

Wenger

JOURNAL

OF CONTINUING

Press:

I'M,

E. I\1cDermotl Press;

Bataldcn

l'rul,III'c\',

Snyder

PB.

Jossey-Hass:

Policy.

Cambridge.

United

education Med

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interprofessional continuing education. IPE addresses the processes by which individuals collaborate and work together to improve patient care-dynamic processes informed by social psychology and complexity theory. Situated learning and communities of practice are fitting models for professionals to learn about II' collaboration through practice and, most importantly, through social interaction and reflection. Social interaction models can also moderate the potentially negative influence of social identity and professional allegiances. stereotypes, and power redistribution upon collaborative learning and practice; however, these topics must be explicitly addressed. Continuing IPE requircs individuals to think in a differ-

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would

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• Social theories also show that IPE content needs to address barriers posed by stereotypes, social identity, and professional socialization.

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health professions education: A systcmatic review. Ad •.fI/!olth Sci Edll/' Theory Proe!. 2007; No.1' 23. 32. Sargeant JM, Mann KV. van der Vleuten cr. Metsemakers JF. Reneclion: A link between receiving and using assessment feedhack. lId" H/!olth Sei I:'dlle Theorv Praet. 2009; 14;399-41 O. .13. Merriam SB. Caffarella RS. Baumgartner LM. L/'omillg ill Ad/liIlwod: A COl/lprehellsi •.e Guide. San Francisco, CA: Jossey-Bass; 200(,. 34. Kegan R. What "form" transforms'} A constructive-developmental approach to transformativc learning. In: Mezirow J. cd. I",!omill!; ".I' h,,"s-

184

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formotion: Criticol Perspectives Oila Theory in Pmgress. San Francisco. CA: .Iossey-Bass; 2000:35. Brooktield S. '/h/llsformative '-eomillg os Id"ology Critiqlle. I"""rnillg as '/i"all.\:!fJrma/ioll:

C6tical

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Francisco. CA: .Iossey-Bass; 2000: 12,';. 36. Mezirow.l. '-""millg to Thillk Uk" oll/\dul!.· Cor" COllceptS o{Tmllsfor/1/ation Tlleorv. Le"millg as '1i-tll1s{or/1/ation: Critimll'erspec{i,'e.1 ()){" Theorv ill Progress. San Francisco, CA: Jossey-Bass: 2000:3. 37. Rogers C, Freiherg 1fJ. rreedol/l /(I '-1'''1'11. Columbus. Olf: Prentice Hall; 1994.

IN THE HEALTH PROFESSIONS-29(3),

2009

Copyr'ight of J our'nal of Continuing Education in the Health Professions

is the pr'opedy

of John

Wiley & Sons, Inc. / Education and its content may not be copied or emailed to multiple sites or' posted to a Iistse r'v without the co py r'ight ho Ide r' I s ex p r'ess wr'itten pe r'miss ion. Howeve r', use r's may pr'int, download, or' email ar'tides for' individual use.

Appendix 3: Executive Summary: Burruss Institute Analysis

The Medical College of Georgia’s Reputation among Peer Faculty and Administrators in the United States

Kennesaw State University 1000 Chastain Road Kennesaw, Georgia 30144‐5591 770‐423‐6464 770‐423‐6395 (FAX) www.kennesaw.edu/burruss_inst

Survey Report: The Medical College of Georgia’s Reputation among Peer Faculty and Administrators in the United States

Introduction The Medical College of Georgia requested that the Burruss Institute conduct a national survey of faculty and administrators at peer institutions to determine the extent to which the Medical College of Georgia has a national reputation, as well as the extent to which other health education professionals understand the scope of the Medical College of Georgia’s mission. A national sample of faculty involved in physician training, faculty involved in other health fields, and university administrators was drawn, and telephone interviewers collected responses between August 31st and September 3rd, 2010. Respondents who were unable to complete the survey by phone, but who were interested in responding to an email option, were surveyed using an online form. In all, 212 respondents participated in the survey. The pool of respondents represent over 70 institutions providing medical and other health education programs, including:  Columbia University  Northwestern University  Johns Hopkins University  New York University  The University of Florida  The University of Colorado  The University of Alabama, Birmingham  The University of Arizona  The University of California at Los Angeles  The University of Virginia  The University of California at San  The University of Texas Health Francisco Science Center This national sample was designed to provide the Medical College of Georgia with a snapshot of its reputation among those working at its peer institutions the country. Respondents also represent various roles played by those who work in medical and health science schools. 51.4% of the respondents were medical school faculty, 28.3% were administrators, 5.2% were faculty from disciplines other than medicine, and just over 10% identified themselves as something other than strictly faculty or administration.

A.L. Burruss Institute for Public Service and Research

Respondents were asked: Q1: Have you heard of the Medical College of Georgia?

And a second question that varied slightly, depending on the respondent’s answer to Q1: If yes: Q2: Is the Medical College of Georgia … a) a stand‐alone medical school? b) a medical school affiliated with another university? c) a comprehensive health sciences university? d) a health system or teaching hospital? e) I don’t know or other?

If no: Q2: Even though you’ve not heard of the Medical College of Georgia, do you think it is: a) a stand‐alone medical school? b) a medical school affiliated with another university? c) a comprehensive health sciences university? d) a health system or teaching hospital? e) I don’t know or other?

The short survey was designed to allow Medical College of Georgia officials to understand the place of the university in the minds of peers in the health education profession. Since the reputation an institution has can have implications for its ability to recruit faculty, place its graduates in jobs, and compete for resources with other schools, it is important for College officials to understand where it stands so it can formulate approaches to maintaining or improving its standing among peers.

A.L. Burruss Institute for Public Service and Research

Results Results from the first question, which asks respondents if they have heard of the Medical College of Georgia, indicates that roughly half of the respondents (51.9%) had heard of the institution. Figure 1: Have you heard of the Medical College of Georgia?

Familiar w/ MCG

51.9%

Not familiar w/ MCG

48.1%

10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Though 51.9% is a majority, 48.1% is a very large minority of respondents who have not heard of the Medical College of Georgia. This result suggests that large numbers of people working in the field of medical and health education have not heard of the Medical College of Georgia. The second question asked of respondents actually has different implications given the two different groups that respond to it. The answers from the group that has heard of the Medical College of Georgia indicate how much this group knows beyond having heard of the school. The answers from the group that has not heard of the Medical College of Georgia, on the other hand, indicate what kind of institution the Medical College of Georgia sounds like to medical and health education professionals. Among respondents who have heard of the Medical College of Georgia, the largest group (28.8%) believe that it is a stand‐alone medical school. The next largest group (27.9%) say that they do not know which option is correct. The correct answer, “A comprehensive health sciences university,” was only chosen by 18% of respondents. This, again, indicates that large numbers of medical and health education professionals have little information about MCG’s mission and activities.

A.L. Burruss Institute for Public Service and Research

Table 1: Is the Medical College of Georgia…BY Familiar with MCG A stand‐alone medical school? A medical school affiliated with another university? A comprehensive health sciences university? A health system or teaching hospital? OTHER DON’T KNOW (DON’T READ)

Familiar with MCG Percent Frequency 28.8 32 8.1 9 18.0 20 9.9 11 7.2 8 27.9 31

Respondents who had not heard of the Medical College of Georgia were asked to guess what kind of institution it was just from the name. This would give an indication of the kind of institution the words “Medical College of Georgia” brought to mind among peers in the medical and health education fields. The results show that, again, a large number of people cannot offer a guess (33.3%), and the largest number of respondents who do guess (28.4%), guess that it is a stand‐alone medical school. Interestingly, those who are not familiar with the Medical College of Georgia, and who are thus simply making a guess based on the name, are extremely unlikely to guess that the name refers to a comprehensive health sciences university. Only one of the 102 respondents who gave a response thought that the Medical College of Georgia would be a comprehensive health sciences university. Given the four options offered to respondents, one would expect that random chance would lead between 20 and 25 respondents to choose this option. The fact that only one respondent considers the correct answer to sound right strongly suggests that the name “Medical College of Georgia” negatively affects the schools ability to build an accurate, national reputation. Table 2: Is the Medical College of Georgia…BY Not familiar with MCG A stand‐alone medical school? A medical school affiliated with another university? A comprehensive health sciences university? A health system or teaching hospital? OTHER DON’T KNOW (DON’T READ)

Not familiar with MCG Percent Frequency 28.4 29 18.6 19 1.0 1 14.7 15 4.0 4 33.3 34

A.L. Burruss Institute for Public Service and Research

Figure 2: Is the Medical College of Georgia… A stand‐alone medical school? A medical school affiliated with another university? A comprehensive health sciences university? Not familiar w/ MCG A health system or teaching hospital?

Familiar w/ MCG

OTHER Don't know 0%

10%

20%

30%

40%

Conclusion This quick study sought to measure the extent to which the Medical College of Georgia has established a national reputation, the extent to which that reputation accurately reflects its mission and activities, and the role the institution’s name plays in assumptions medical and health education professionals have about its likely mission and activities. Results indicate that, while a slight majority of respondents have heard of the school, large numbers of professionals at peer institutions have not heard of the Medical College of Georgia. Among those who have heard of it, most either do not know enough to elaborate on its structure or believe that it is simply a stand‐alone medical school. Finally, when those who have not heard of the school are asked to guess about the details of its structure, only one in one‐hundred‐and‐two guessed that it is a Comprehensive Health Sciences University. Taken as a whole, this study suggests that the Medical College of Georgia’s name is misleading, and that accurate information about it is scarce among professionals working at its peer institutions.

A.L. Burruss Institute for Public Service and Research

Appendix 4: GHSU and MUSC: A Study of Nearly Identical Twins

GHSU and MUSC: History of Nearly Identical Twins • Both universities are located in same area of the country, 180 miles apart • MUSC was founded in 1824 and GHSU in 1828 • Both became universities in 1950 • MUSC opened its own hospital in 1955 and GHSU in 1956 • The MUSC Foundation was founded in 1966 and the MCG Foundation in 1954 • MUSC is located in a metro area of approximately 660,000 and GHSU is in a metro area of 540,000

GHSU vs. MUSC By the Numbers GHSU

MUSC

% difference

$91 million

$146 million

+60%

$47.3 million

$117.3 million

+150%

Clinical Gross Charges

$1.7 billion

$2.2 billion

+30%

Square Footage

5.25 million

7.6 million

+45%

967

1,349

+40%

2,438

2,514

+3%

632

709

+12%

165

Down from 161

Up from 95

Size of Endowment Grant Funding

Faculty Students Hospital Beds US News & World Report ranked Clinical Specialty Areas Ranking among research universities

Growth and Investment at GHSU vs. MUSC Student Faculty Endowment Facility Growth Growth (%) Growth (%) Growth (%) (sq. ft.) past 10 past 8 years past 10 years past 5 years years

GHSU

(2)

(12)

MUSC

763,889 2,059,395

GHSU vs. MUSC Campus Data Building Age Comparison (Square Footage)

Enterprise Sq. Ft

Total Enterprise

GHSU vs. MUSC Campus Growth & Age • Growth in research & academic facilities in the past 30 years: • At MUSC – 2.9 Million sq ft. • At GHSU – 0.7 Million sq ft.

• Growth in clinical facilities in the past 30 years: • At MUSC – 1.6 Million sq ft. • At GHSU – 1.4 Million sq ft.

• At GHSU 81% (43) of university and 53% (10) of hospital bldgs, are >30 years old • At GHSU a 55 year old hospital building vs. a 3 year old building at MUSC

WAITING ON NEW SLIDE FROM MEEHAN

Philanthropy – MUSC vs. GHSU

• Similar trends until 1998, then significant & growing discordance in fund‐raising • Offset some by better returns on investment

Why Are We Outmatched by Our Twin? • Limited investment in the facilities and capital structures necessary to accommodate: – The growing demands of health professions expansion – The growing needs of contemporary and future research & discovery – The growing requirements and advances of the health care delivery environment

Why Are We Outmatched by Our Twin? • Limited philanthropic support • Long‐term under‐investment by Community – Perception of being a State entity – Inadequate appreciation of economic value – Inconsistent relationship between University and the surrounding Communities of Georgia

Potential reasons for chronic underinvestment Late focus on research & discovery (~2000) Unclear identity and objective Paucity of grand and long‐term vision Limited fundraising efforts Persistent silos throughout Paucity of ongoing self‐assessment, rigorous measurement, and clear accountability • Location • • • • • •

– … The Atlanta effect on philanthropy – … The South Carolina effect on perception of size

Augusta and Charleston: A Demographic Snapshot • Charleston is faster growing – 26% growth in population over past ten years vs. Augusta’s population increase of 17%

• Charleston is somewhat better educated – 29% of the city’s residents have bachelor’s degrees or higher vs. 22% of Augustans

• Charleston is somewhat wealthier – Mean household income is $5,000 more than that of Augustans – Over past 15 years, number of Charlestonians in poverty decreased by 4% while Augustans in poverty increased by nearly 13%

Appendix 5: Current and Future Clinical Delivery Platforms

Current Complex Care Services (3ď&#x201A;° and 4ď&#x201A;° disease)

Currently serving 3,200 patients with complex disease

Note: Actual = Number of MCGHI patients from region; Market estimate includes patients currently going to Florida Source: GA CY09 Discharges; Chartis Analysis; 3218 discharges includes 52 cases from outside of Georgia & S. Carolina

"Confidential. Commercially valuable plan, proposal or strategy."

Future Complex Care Services (3 and 4 disease) @ 0% = 0 Actual = 3 @ 0% = 0 Actual = 48

@ 0% = 0 Actual = 43 @20% = 392 Actual = 84

@45% = 3,928 Actual = 2,433

@ 0% = 0 Actual = 0

@ 45% = 456 Actual = 174

@35% = 497 Actual = 92

@ 20% = 176 Actual = 32

@ 20% = 370 Actual = 56

@45% = 354 Actual = 129

@ 50% = 1,568 Actual = 72

In the future, serve 6,400 patients with complex disease Out of State Actual = 52

"Confidential. Commercially valuable plan, proposal or strategy."

ONLY THE BEGINNING!!! MCG Health, Inc. Current Network Partners Enhanced Possible Expanded Network Pediatric Service Lines Oncology Service Lines

"Confidential. Commercially valuable plan, proposal or strategy."

Appendix 6: Tertiary/Quarternary Outmigration by Service Line

Tertiary/Quaternary Outmigration by Service Line Cardiothoracic Services, Neonatology, General Surgery and Spine account for 55% of outmigration cases leaving their local referral regions Tertiary/ Quaternary Outmigration by Service (2009)

Service Line

Cardiology Neonatology CT Surgery Gen. Surg. Spine Gen. Med. Cancer Pulmonary Pediatrics Orthopedics Trauma Neurology Neurosurgery Gastro Transplant Vasc. Surgery Grand Total

SE SW Georgia Athens N. Athens Georgia

583 377 382 287 251 220 173 178 126 172 79 105 58 13 24 25 3,053

362 200 133 309 266 210 226 191 181 160 236 158 147 135 119 92 47 137 70 71 57 50 84 47 45 50 23 22 10 22 17 14 2,023 1,868

309 292 197 145 141 94 139 108 121 43 47 51 50 12 26 16 1,791

Atlanta

158 205 112 170 146 187 81 117 31 102 106 76 36 14 7 11 1,559

Macon

85 79 112 176 129 105 141 92 134 76 48 60 38 10 34 7 1,326

SC Ext. Albany Augusta Savannah SC Sec Columbus

84 46 97 133 71 49 70 53 44 45 147 28 41 7 10 6 931

77 85 67 90 129 51 46 58 95 36 38 24 27 5 11 6 845

91 80 91 72 62 81 60 44 40 49 17 25 7 6 13 8 746

67 47 72 72 43 41 62 29 75 47 35 18 7 6 29 6 656

44 42 51 61 41 31 13 38 5 17 34 10 5 5 2 2 401

Source: GA and FL 09 Discharges; Chartis Analysis; Excludes MCGHI cases; Excludes Dermatology (15) and Endocrinology (25) and ungrouped discharges (2); "Confidential. Commercially valuable plan, proposal or strategy."

Total

36 2,096 23 1,718 28 1,685 54 1,677 5 1,359 22 1,275 41 1,108 18 946 60 915 18 746 24 682 8 536 14 378 1 124 8 196 1 119 361 15,560

Appendix 7: Impact by Segment for Inpatients

Impact by Segment: Inpatient There is a large difference between general (primary and secondary) and complex (tertiary/ quaternary) volume and a smaller difference between Government and Private volume

Self-Pay

Other

Government

Private

Complex

General

708 individuals 4% of total

4,014 individuals 21% of total

$43,296 Rev/Disch

$7,229 Rev/Disch

$20,968 CM/Disch

$2,973 CM/Disch

2,180 individuals 11% of total

10,204 individuals 52% of total

$39,095 Rev/Disch

$8,737 Rev/Disch

$18,764 CM/Disch 41 individuals <1% of total

$4,487 CM/Disch 323 individuals 2% of total

$6,975 Rev/Disch

$5,850 Rev/Disch

($2,502) CM/Disch 205 individuals 1% of total

($3,432) CM/Disch 1,796 individuals 9% of total

$13,825 Rev/Disch

$2,882 Rev/Disch

($5,685) CM/Disch

($620) CM/Disch

Source: TSI FY09 Discharges; Chartis Analysis "Confidential. Commercially valuable plan, proposal or strategy."

Appendix 8: Strategic Partnerships and Affiliation Tools

Strategic Partnership and Affiliation Tools  GHSU & Georgia Health Sciences Health System brand and imprimatur  Extending the Hospital-based Management & Staffing Services Platform • Emergency Medicine • Radiology and Imaging • Pathology and labs • Hospitalist and Intensivists • Specialty back-up  Extending the Technology Management & Staffing Services Platform • Electronic Health Records (Cerner) • Electronic Imaging (PACS) • Tele-medicine/tele-health  Access to Residents, Fellows, Nursing, Allied Health providers and Dental Health  Continuing (Medical) Education  Management expertise & oversight for building effective Graduate Medical Education (GME) programs

 Hospital Management Services  Physician Management Services Organization offerings • Health professions recruiting • Executive management – interim, permanent • Physician office management  Linkages to new primary care ( 1o / first-level 2o care delivery models) particularly to Family Practice; Internists; Nurse Practitioners; Physician Assistants; Obstetrics  Service Line Linkages • Heart and Cardiovascular • Cancer and Phase 1 trials • Neurosciences and REACH • Pediatrics/Children’s/Women’s subspecialists • Digestive Diseases  Linkages to new health plan design, ACO’s, value based services

Appendix 9: Cancer Center Position Paper

GEORGIA HEALTH SCIENCES UNIVERSITY

Cancer Research Center A rationale for continued investment Eliminating $2.5 million in state funds for the Georgia Health Sciences University (formerly Medical College of Georgia) Cancer Research Center will reverse the positive gains in research and treatment achieved over the past seven years. The reductions will further limit GHSU’s ability to become a national leader in cancer research, jeopardize continued progress toward National Cancer Institute designation, and impede GHSU’s ability to combine research excellence with clinical and educational excellence to improve the health of Georgians. GHSU requests $5 million per year over the next five years to sustain forward momentum in research and care and to continue efforts to achieve National Cancer Institute designation for GHSU’s Cancer Research Center. Background and Context •

•

• • •

•

• •

•

Almost 40,000 Georgians are diagnosed with cancer each year. Georgia averages approximately 15,000 cancer deaths a year, with an annual death rate of approximately 187 citizens for every 100,000 people, which exceeds the national average. More than 80 percent of Georgia’s counties exceed the national cancer death rate, with some of the state’s small, rural counties posting annual rates in excess of 250 deaths per 100,000 people. Despite high incidence of cancer among its rapidly growing and largely rural population, Georgia is home to only one of the nation’s 66 NCI-designated cancer centers. Georgia’s sole NCI center (Emory University’s Winship Cancer Institute, which is located in Atlanta and serves a largely urban patient population) was designated in 2009. In comparison, the University of Alabama Comprehensive Cancer Center was one of the first 11 comprehensive centers designated by the NCI in 1972. And North Carolina, a state with a smaller and slower growing population, has three designated cancer centers – at Duke, UNC-Chapel Hill, and Wake Forest University. Over the past five years, GHSU has sustained budget reductions in excess of $40 million, more than 25 percent of state appropriations. Each reduction has stressed GHSU’s ability to meet the tri-partite mission of the state’s only public health sciences university. Last year’s $2.5 million reduction in Cancer Research Center funding resulted in drastic cuts in core support. Eliminating the state’s $2.5 million contribution in FY2012 will halt strategic growth, necessitate further reductions in current operations, and fail to leverage the significant advances achieved with previous state support, essentially hamstringing the ability of the state’s academic health center to advance wellness, relieve suffering, and reduce cancer mortality in Georgia. The state support requested for the GHSU cancer program is a fraction of what is needed to propel the cancer center to national prominence and NCI designation.

Plans for Growth The GHSU Cancer Research Center facility was completed in 2006 and currently houses approximately 35 funded research faculty and 175 associated personnel conducting research in areas such as cancer immunology/immunotherapy, developmental therapeutics, molecular oncology, and cancer prevention/control. In 2010, GHSU complemented this outstanding facility with the MCGHealth Cancer Center, which offers multidisciplinary patient- and family-centered cancer treatment and supports vital clinical research. These significant capital investments have created the infrastructure to fully realize “bench to bedside” treatment. The MCGHealth Cancer Center, for example, is the first of its kind in Georgia to offer Phase 1 and Phase 2 clinical trials and currently participates in nearly 150 studies. Future plans include include the expansion of our statewide network for clinical trials by partnering with oncology practices in the cities that are home to GHSU’s regional campuses. Additionally, we have a goal of doubling our Federal research dollars over the next five years. Return on Investment The state of Georgia has committed $5 million per year to GHSU’s cancer program beginning in FY2006. Research outcomes have exceeded expectations with a solid return on investment. GHSU cancer research has grown from $9.5 million in FY 2005 to $26.4 million in FY 2011, a nearly three-fold increase in five years. The state’s support has been vital to this initiative, but sustained investment is necessary if GHSU is going to achieve NCI-designation. Indicators of GHSU’s broader return on investment include the following: • • • •

In 2010, the GHSU generated $8.3 billion in the Georgia economy through direct operations, affiliated health providers, commercial spin offs, and contributions to the state’s workforce. More than one of every $50 dollars of the state’s economy is supported by GHSU operations. Nearly 50,000 total jobs statewide are supported by GHSU. By 2020, the total economic impact of GHSU is estimated to generate $11.8 billion in the Georgia economy.

GHSU has demonstrated that it is a sound investment of public funds, a good marker of the return on investment on future funds that are dedicated to the enterprise’s cancer center operations and strategic growth. First-rate cancer centers improve health outcomes and contribute to robust economic development. National Cancer Institute designation for GHSU would present a major opportunity to improve the health of the state’s people and the health of the state’s economy, yielding substantial dividends for generations to come.

Julie Kerlin, Government Relations 706-836-9343

February 2011

Appendix 10: What the CSRA Will Look in 2020

Appendix 10: What the CSRA Will Look Like in 2020 Augusta is the principal city of the Augusta‐Richmond County Metropolitan Statistical Area, which has a total population of approximately 540,000, making it the second‐largest city and second‐largest metro area in the state after Atlanta, as well as the 116th largest city in the United States. As the anchor of the MSA, the city of Augusta and Richmond County have a combined population approaching 200,000. While Augusta is best known for hosting the Masters Golf Tournament each spring and for being the hometown of funk/soul singer James Brown, the city is also a major center for medicine and the health sciences, the largest employer in the region and a catalyst for the area’s future economic growth. In recent years, numerous efforts have been undertaken to articulate a vision for the broad community – and more focused subsets of the region. The outcomes of these visioning efforts – sound attempts to address the question of what our community will look like in the future – are summarized below. Destination 2020 Destination 2020 was a volunteer effort coordinated by the Metro Augusta Chamber of Commerce that articulated a future for Augusta centered around 18 segments, such as arts and culture, community service, education, health care and medicine, housing, and transportation. ‘Visions’ of particular relevance to this document’s focus include: 

 



EDUCATION – Education in the Augusta Region in the year 2020 is vibrant, inclusive, empowering, comprehensive, and seamless. Our citizens value and embrace education as an essential element for an ideal quality of life, and our region has benefited socially and economically from this renewed focus on learning. HEALTHCARE AND MEDICINE – In 2020, the Augusta Region is a region known for the innovative steps it has taken toward providing quality healthcare for its citizens while at the same time nurturing efforts for improving healthcare all over the world. MEGA PROJECTS – In the year 2020, the Augusta Region is the premier mid‐sized metropolitan region in which to live, work, and play. The region’s prosperity and desirability are due in part to the implementation of a group of “mega projects.” o Of the ten strategies included in the Destination 2020 report for this ‘vision,’ one relates to the establishment of a biomedical center, another to the establishment of a cancer research center. DOWNTOWN – In 2020, downtown Augusta looks and feels like the heart of the region. Citizens throughout the greater metro area region take pride in and enjoy the distinct character of our urban center.

Realizing the Garden City: The Augusta Sustainable Development Agenda The effort originated from a sense within the city leadership that, more than a decade after consolidation with Richmond County, the diverse parts of the enlarged city had not yet coalesced into a unified community with a common and sustainable vision of how Augusta should evolve. The effort resulted in the identification of projects and recommended actions in urban, suburban, and rural Augusta that would result in higher quality of life for the residents of the ‘Garden City.’ Projects of particular interest to GHSU include:  

Creation of opportunities to expand health sciences businesses near the existing medical complex. Attracting a new, resident‐based college or university to the downtown district.

Overall, the plan is focused on increasing economic activity and vitality of the Augusta region, protecting and enhancing the environment and its resources, reinforcing livable communities and neighborhoods, and creating effective and attractive regional linkages.

The Westobou Vision: 2009 Master Plan for a Sustainable Future The Westobou Vision is the work of Augusta Tomorrow, a master plan for the Augusta/North Augusta urban district. The plan, which characterizes Augusta’s health sciences industry as a key attribute of the urban area, includes three over‐arching goals for the downtown districts of Augusta and North Augusta, South Carolina:   

Linked Garden Cities … in the midst of a green and natural region with a green environment, waterfront, recreation, and proximity to nature A Center for Learning and Innovation … providing extraordinary health services, research, science, and education A Vibrant Place to Live, Work, and Play … with high‐quality in‐town living, culture, and arts

Additionally, the plan identifies dedicated districts within the urban area, one of which is the Medical District. Bounded by Walton Way, 10th, 15th, and Reynolds Streets, the Medical District – according to this master plan – could be developed into a powerful entity that competes on the national level for both health sciences research and treatment. Additionally, the plan highlights the area’s mills and canal system, which provide an attractive amenity to lure health sciences development into a park setting. In combination, these plans envision the Augusta of the future as a safe, green, smart, prosperous, cooperative, and healthy community – a vision that leaves much room for significant contributions from Georgia Health Sciences University in light of our tripartite mission of education, research, and clinical care. In 2008, the city of Augusta, working in conjunction with federal housing officials and university administrators, negotiated the transfer of the 15 acre “Gilbert Manor” property to the university, which involved the closure of the housing project located on that site. This gift from the city, valued at $10 million, including roughly $3 million for the purpose of demolition and site development, enabled the university to plan the development of, and obtain approval for, the new College of Dental Medicine and Education Commons. Clearly, the city has a vested interest in the success and growth of the university and understands the importance of the university to local economic development. Georgia Health Sciences University continues to be actively engaged with the city of Augusta on the future development of the campus and medical center. Ongoing discussions with city officials are occurring on issues ranging from the redesign of the Laney‐Walker Boulevard corridor to student housing and, more recently, the opportunity to collaborate on the financing of a new facility for the Institute for Public Health. The city’s support is essential to the university as well. As we plan new growth in the Augusta/CSRA region, it will be vitally important that we work in close partnership with local leadership and residents.

Appendix 11: GHSU Sources of Funding

Sources Of Funding Internal: Clinical Increased Operating Margins From Recontextualization: RTX = Cost and ALOS Reduction Initiatives

FY 12

FY 13

FY 14

FY 15

FY 16

FY 17

FY 18

FY 19

FY 20

Total

$22.0

$51.5

$69.0

$556.5

($3.0)

($7.0)

($13.0)

($18.0)

($113.0)

$35.0

$315.0

$8.0

$18.0

$20.0

$22.0

$156.0

$1.4

$2.7

$4.1

$4.3

$4.5

$4.8

$31.4

$9.0

$14.0

$18.0

$135.0

$2.0

$10.5

$2.0

$4.0

Impact of Reductions in GME/IME, DSH & Other Funding From State & Federal Programs Annual Cash Flow Reserved for Ongoing Capital Expenditures Service Reconfiguration Initiatives: More Complex Teriary/Quaternary Care Revenue Cycle & Managed Care Contracting Optimization Initiatives Clinical Productivity Enhancement / Reduction in Levels of Unfunded Research PPV 50% Financing For Parking Structure

$35.0

$4.0

$12.5

Internal: Philanthrophy Incremental Levels of Philanthropy & Endowment Income‐‐For Donor‐Specified Programs or Capital Items Special Philanthropic Gifts For Education Commons Building

$2.0

$8.0

$11.0

$13.0

$14.0

$16.0

$17.0

$15.0

$87.0 $15.0

Internal: Education Incremental Tuition Revenues from Enrollment Growth, Increased Out‐of‐State Students (Modest Inflationary Adjustments Already Absorbed By Ongoing Operating Needs)

$1.5

$2.4

$5.3

$6.8

$9.5

$11.3

$59.4

$63.0

$1.0 $3.5 $126.9

$2.0 $8.0 $158.6

$4.0 $15.0 $165.4

$6.0 $24.0 $178.1

$9.0 $32.0 $194.0

$11.0 $40.0 $207.1

$11.0 $40.0 $209.1

$11.0 $40.0 $210.1

$55.0 $202.5 $1,512.3

$0.0

$10.0

$80.0

$0.0 $0.0

$3.0 $13.0

$9.0 $19.0

$12.0 $22.0

$15.0 $25.0

$99.0 $179.0

Internal: Research Increased F&A Funding Incremental Grant Funding: NIH

Total: Internal Funding Sources State Funding SFI Funding for Cancer Research Center State Formula Funding Changes That Brings Balance & Greater Equity for GHSU

Total: State Funding Sources Debt General Obligation Bonds Debt Issuance: GHS Medical Center

$35.0

$45.0

Total: Debt

$0.0

$35.0

$100.0 $100.0

Total Sources of Funds

$63.0

$174.9

$277.6

$45.0

$155.0 $155.0

$0.0

$80.0 $255.0 $335.0

$232.4

$358.1

$219.0

$232.1

$234.1

$235.1

$2,026.3

Appendix 12: Closing the $100M Gap

To Fulfill our Aspirations, We Would Close a $100M â&#x20AC;&#x153;Gapâ&#x20AC;?

Margin Target 5.5%

$80

$75

No Management Intervention Minimal or Ad Hoc Management Intervention Moderate Level of Management Intervention Aggressive Level of Management Intervention

$60 $50

$50 Margin Target 3.5%

$40

$40 $25

$20

$25 $15 $15

Hold FY12 + Additional $32M target reduction

$10 $FY 2012

$(20)

$28M target reduction

Margin Target 2.0%

FY 2013

FY 2014

($13) ($20)

($25) Margin Target N/A

$(40)

Hold FY12 & FY13 + Additional $15M target reduction

Appendix 13: Initiatives Driving Financial â&#x20AC;&#x153;Turnaroundâ&#x20AC;?

Appendix 13: Initiatives Driving Financial “Turnaround”                 

Fine‐tune the clinical enterprise operations, quality and efficiency to bring better operating margins for the enterprise, and better service for patients. This must be done before significant reinvestments in additional research and clinical capacity are built. Simultaneous with rebuilding operating margin levels to respectable levels, accelerate efforts on our clinical repositioning strategy, thus building greater capacity and programmatic ability to address the needs of referred complex tertiary and quaternary cases. Build our organizational capability for raising large gifts and pledges for future facility and program expansion. Secure significant pledges and convert them to cash donations to be utilized for designated new buildings. Secure G.O. Bonds and philanthropic sources to fund 90 percent of the cost for the new Education Commons facility, with this building to be completed before the end of FY 2013. Complete the expansion of the Bone Marrow Transplant unit. Assess and implement any required changes in processes and incentives to support enhanced faculty productivity in selected areas. Complete efforts associated with rebuilding our surgery faculty, support infrastructure and equipment, and related processes to enhance throughput, quality, and growth in surgical case volumes. Close on the recruitment of a world‐class clinical leader for our Cancer program and a strong and visionary leader for our research mission. Start detailed design for a renovated and/or modest new‐build of acute care facilities to address highly complex surgical and medical patients, e.g., more universal rooms, more ICU capacity, etc. Expand our reach and network of potential referrals by building relationships with community‐based hospitals and physicians whose patients would be advantaged by our proximity, cost, quality, and service dimensions. Build space to meet the transitional needs for an Institute for Public Health. Begin recruitment of clinical and basic scientists to utilize the capacity of our existing Cancer Research Center and to build the faculty that will eventually be located in a new research facility devoted to programs other than cancer research. Deploy additional revenue enhancement tactics to yield additional revenues per unit of service, inclusive of negotiating aggressively with commercial managed care payers for rate increases that provide the GHSU clinical enterprise with modest margins above its total costs of service delivery. Absorb the impact of certain reductions in funding for graduate medical education and disproportionate share. Continue to make progress on patient throughput, bring the average length of stay (ALOS) down to a level between 4.80 and 5.00 days. Obtain some modest increase in state formula funding that recognizes our unique situation regarding student enrollment levels [lower] and costs per student [higher] relative to general higher education institutions. Increase tuition revenue from anticipated enrollment growth and reasonable annual rate increases over the ensuing several years.

Appendix 14: Tripp Umbach Report

Georgia Health Sciences University Economic Impact Study 2010‐2020

PREPARED BY: TRIPP UMBACH

Contents Background ................................................................................................................................................... 2 Executive Summary ....................................................................................................................................... 0 Strategic Moves toward a Healthier Economy ............................................................................................. 7 Operational Impact: ............................................................................................................................. 7 Affiliated Healthcare Providers Impact: ................................................................................................ 8 Industry Impacts: ................................................................................................................................. 9 Workforce Impacts: ........................................................................................................................... 10 State of Georgia Economic Impact Findings of Georgia Health Sciences University .................................. 12 State of Georgia Economic Impact of Georgia Health Sciences University – Breakout .............................. 13 State of Georgia Employment Impact of Georgia Health Sciences University – Breakout ......................... 15 State of Georgia Government Revenue Impact of Georgia Health Sciences University – Breakout .......... 17 Physician Graduates who Practice in the State of Georgia ......................................................................... 18 Impact of Growth in Research and Bioscience Industry on the State of Georgia ...................................... 19 Conclusion ................................................................................................................................................... 22 Appendix A: Tripp Umbach Qualifications ................................................................................................. 23 Appendix B: Methodology Employed in the Economic Quantification Study ........................................... 24 Appendix C: Detailed Direct Economic Impact Findings of Georgia Health Sciences University’s Operations in 2010...................................................................................................................................... 27 Appendix D: Definition of Terms ................................................................................................................ 29

BACKGROUND

Government revenue that is collected by governmental units in addition to those paid direct by an Tripp Umbach was invited by the Board of Regents of the University System of Georgia on institution, including taxes paid directly by employees of the institution, visitors to the institution, and behalf of the Georgia Health Sciences University (GHSU) to complete a comprehensive vendors who sell products to the institution. statewide economic impact assessment of all operations and activities of the University, including its many clinical, educational, and research programs throughout the State of Georgia. This study represents an update to an economic impact analysis completed by Tripp Umbach in early 2007 at a time when GHSU (formerly Medical College of Georgia) was in the planning process for regional campus expansion. It is important to note that during the process of completing the update study, the University went through a name change. As of February 1st, 2011, Medical College of Georgia officially became Georgia Health Sciences University. Georgia Health Sciences University entities name changes are as follow: o The School of Allied Health Sciences is the College of Allied Health Sciences o The School of Dentistry is the College of Dental Medicine o The School of Graduate Studies is the College of Graduate Studies o The School of Medicine is the Medical College of Georgia o The School of Nursing is the College of Nursing Economic, employment and government revenue impact findings presented in this report are presented at the entire university level (Medicine, Dentistry, Nursing, Allied Health Sciences, and Graduate Studies). The study required Tripp Umbach to develop customized economic impact measurement protocols that profile:  Statewide Operations: The current FY 2009/2010 economic benefits associated with the statewide operations and partnerships of GHSU and its affiliate organizations (Medical College of Georgia, Other Non‐COM components of GHSU, MCG Health System Inc. and the Physician Practice Plan). Note: All economic impact findings presented in this report are based on Fiscal year (FY) 2009‐2010 and will be referred to as 2010 throughout the report.  Historical and Future Growth: The historical growth in economic impact of GHSU over the period 1995 through 2010 and future economic benefits of GHSU on the statewide economy (2015 and 2020).  Business Spinoffs: The business enterprise formations and expansions in the state related to pure and applied research conducted at the proposed GHSU expanded medical college and its constituent institutions.

 Workforce: The economic, employment and government revenue impacts associated with graduating physicians who graduate from GHSU Medical College of Georgia and remain in the State of Georgia after graduation to practice medicine.  Community Benefits: The multiple additional economic and social values that GHSU brings to the State of Georgia in terms of healthcare workforce; medical tourism, spin off commercial development based on primary research, and charitable contributions and volunteerism.  Return on Investment: The Return on Investment to the State of Georgia from funding provided to GHSU.

Georgia’s Economic Future The last decade for Georgia Health Sciences University has yielded strategic, phenomenal growth in educational, research and clinical initiatives. These dynamic changes have added billions of dollars to the Georgia economy with billions more to be added as the University achieves its vision of becoming a leading academic health center and a top 50 research university. Theses dynamic changes will transform the institution and the region into a health care and biomedical research destination.

Georgia’s Leader in Health Professions Education: College of Medicine, Dentistry, Allied Health, Nursing and Graduates Studies Georgia Health Sciences University trains the majority of physicians, dentists, nurses, technologists and administrators who server every community in the state. Education has been the university’s highest priority throughout its 183‐year history.

Medical College of Georgia: A 2010 freshman medical school class of 230 students puts MCG among the 10 largest medical school classes in the country. Class size will grow to 300 within the next 10 years to meet physician workforce needs. The large freshman class, up from 190 students in 2009, includes students at the new, four‐year GHSU/UGA Medical Partnership campus in Athens. The Athens campus is part of medical school expansion plan that is occurring at the home campus in Augusta as well as at clinical campuses, in Southwest Georgia, based at Phoebe Putney Memorial Hospital in Albany, Southeast Georgia Clinical Campus based at St. Joseph's/Candler Health System in Savannah and Southeast Georgia Health System in Brunswick and in Northwest Georgia in Rome, GA. The Athens campus, a partnership between two Georgia research universities also will enable expansion of the M.D.‐Ph.D. program as well as research initiatives at both universities. By July 2013, the Northwest Georgia Clinical Campus of the Medical College of Georgia School of Medicine in Rome, GA will be established. MCG medical students already learn alongside physicians of Rome's famed Harbin Clinic, the state's largest physician‐ owned multispecialty group, spending four‐ to six‐week rotations studying internal medicine or pediatrics. The clinical campus will expand the number of third‐ and fourth‐ year medical students who get a portion of their education in Rome and Northwest Georgia. Rome is an exceptionally cohesive medical community with state‐of‐the art facilities and a community‐wide vision of being a more comprehensive component of the Georgia Health Science University’s teaching network. GHSU’s expanding partnerships with physicians and hospitals throughout Georgia are enabling students to get a variety of excellent clinical experience, from small community practices to tertiary care facilities. GHSU is also leading a statewide initiative to foster expansion of residency training which is necessary to grow more physicians for Georgia. Consolidated Education Commons (CMEC) Building: The delivery of Medical and Dental education has advanced significantly in the past 20 years. The proposed Education Commons will incorporate technology to keep abreast with the contemporary delivery of Medical and Dental education. The Education Commons building and the renovation/ expansion of existing Gross Anatomy space will include classrooms and teaching labs, clinical skills and simulation center, medical college administration offices, amenities, common areas and general building support areas. The new commons building will be adjacent to, and connected with, the new College of Dental Medicine building, which is currently under construction. Both Schools will share facilities within the new Education Commons to foster a collaborative approach to teaching. The Education Commons project will allow GHSU to increase the class sizes of the Medical College of Georgia and College of Dental Medicine to better meet the Healthcare profession needs in Georgia.

College of Dental Medicine: Since the graduation of its first class in 1973, the College of Dental Medicine ‐ the State‘s sole dental school and one of only 56 in the entire United States ‐ has demonstrated an exemplary record of protecting the oral health of our State’s residents. Over 1,500 students have graduated in the last 30 years, and an impressive 85 percent have remained in Georgia to establish practices. Approximately one quarter of Georgia’s licensed dentists have graduated from the School. College of Dental Medicine has a new home: Construction of the five‐story facility for the state's only dental school began in October 2009 and is slated for completion in June 2011. The $112 million, 268,788‐square‐foot building will be more than 100,000 square feet larger than the existing building, which opened in 1970 on Laney Walker Boulevard. The expanded space of the new facility will allow the school to increase its class size incrementally from 63 to 100 by 2016, and its residency positions from 44 to 72. The growth should help alleviate the shortage of dentists in the state, which has 41.4 dentists per 100,000 citizens— considerably fewer than the nationwide ratio of 54.3 per 100,000, according to the American Dental Association. Approximately 80‐85 percent of College of Dental Medicine graduates practice in Georgia.

College of Allied Health Sciences: The College of Allied Health Sciences now offers over 40 degrees and certificates in 15 disciplines, covering a variety of specialties that are administered through 8 departments: Biomedical and Radiological Technologies, Dental Hygiene, Health Informatics, Medical Illustration, Occupational Therapy, Physical Therapy, Physician Assistant, and Respiratory Therapy. Evolutionary change has been a hallmark of the school in its ability to adapt and meet the needs of the community without comprising the standards of excellence embodied by its founders. Although the College recently celebrated its forty‐second anniversary, some of their academic programs have been offered for well over 50 years. A new Health Sciences Building was built in 2007, which houses the Colleges of Nursing and Allied Health Sciences, and features labs and classrooms where students can use state‐of‐the‐art technology. The building is also where faculty from both school’s see patients. The building features three large, auditorium‐style classrooms and two classrooms equipped with distance‐learning technology, where students and professors can communicate with educators off‐site, including those at the College of Nursing’s satellite campuses in Athens and Columbus.

College of Nursing: The College of Nursing’s past, present and future focus has been and continues to be preparing nurses as outstanding health care leaders for the State of Georgia and beyond. The College of Nursing faculty is dedicated to the integration of teaching, research, and practice, ensuring that every graduate is prepared to reach the farthest ends of his or her career goals. In The College of Nursing’s innovative nursing faculty practice, clinician‐teachers role model exemplary advanced nursing practice for students in community and acute care settings. In the College’s Center for Nursing Research, faculty investigators enthusiastically mentor students who are conducting their research and are serving on existing research teams. In the simulation centers, students practice new skills on state of the art, computerized human simulators in a "virtual hospital" before entering the actual health care setting. These are just a few examples of the College’s student‐centered approach to nursing education.

College of Graduate Studies: Since 1951, the College has provided outstanding training and education for students enrolled in programs leading to the Doctor of Philosophy, combined Doctor of Medicine/Doctor of Philosophy, Master of Science, Master of Health Education, and Master of Science in Nursing and Doctor of Nursing Practice degrees. The College of Graduate Studies' approximately 230 faculty members are selected based on experience in research and education. They are drawn from the faculties of GHSU's College’s of Allied Health Sciences, Dentistry, Medicine and Nursing. Class sizes are small, and our faculty excels in cultivating supportive, collegial relationships with students. The graduate student body is drawn from accredited institutions in the United States and recognized foreign institutions. Their studies in the College of Graduate Studies involve programs encompassing the biomedical sciences, nursing and the allied health professions.

Executive Summary The Key Findings portion of the report presents economic, employment and government revenue benefits related to all components of Georgia Health Sciences University in 2010 and projected impacts for 2020. The total economic impact of the institution includes both the direct economic impact and the indirect economic impact generated in the economy as a result of spending by the institution and attraction of fresh dollars from outside of the state. Direct impact includes items such as institutional spending, employee spending, and spending by out‐of‐ area visitors to the institution. Indirect economic impact, also known as the multiplier effect, includes the re‐spending of dollars within the local economy. Local companies that provide goods and services to an institution increase their purchasing, creating a multiplier. Economic impact findings presented in this report are based on both current data supplied to Tripp Umbach by Georgia Health Sciences University as well as information from Tripp Umbach’s national database of every medical school and hundreds of teaching hospitals. Economic impact findings are also based on advanced research, commercial spin‐off and workforce development models developed by Tripp Umbach.

Direct economic impact includes items such as institutional spending, employee spending, and spending by out‐of‐area visitors to the institution.

Indirect economic impact, also known as the multiplier effect, includes the re‐spending of dollars within the local economy.

Direct employment impact is total employees based on Full‐Time Equivalents (FTEs). Indirect

employment impact is the additional jobs created as a result of the University’s economic impact. Local companies that provide goods and services to an institution increase their number of employees as purchasing increases, creating an employment multiplier.

In addition to presenting economic impact findings, the report provides an overview of various community benefits and global impacts of Georgia Health Sciences University and expanded campuses and the future expansion related to improved healthcare access and improved quality of care. The diagram on the next page illustrates the multiple economic benefits that Georgia Health Sciences University’s future expansion will have on the Georgia economy in a manner such as a “rock hitting a pond”.

Total government revenue impact includes wholesale, retail, service sector spending as well as value added in the manufacturing process.

Indirect government revenue consists of that is collected by governmental units in addition to those paid direct by an institution, including taxes paid directly by employees of the institution, visitors to the institution, and vendors who sell products to the institution.

Workforce Bio‐Science Economic Development Growth

Healthcare Provider Growth

Commercialization of Research

Health Sciences Program Growth

Regional MD Expansion Georgia Health Sciences University Economic Impact Ripple Effect Image, Source: Tripp Umbach

Strategic Moves toward a Healthier Economy In 2010 the total economic impact of GHSU operations (including future partnerships with academic institutions, such as the University of Georgia), affiliated healthcare providers (including only non‐owned hospitals, healthcare providers and public health organizations), industry (including growth in existing companies and commercial spin‐offs), and workforce (including graduating physicians who have remained in the State of Georgia to practice medicine) generated $8.3 billion in the Georgia economy. Today more than one out of every $50 in the state’s economy is supported by GHSU’s operations. Beyond driving the economy, GHSU operations, impacts to affiliated healthcare providers, industry, and workforce also supports thousands of jobs statewide. In 2010, nearly 50,000 total jobs statewide were supported by Georgia Health Sciences University. By 2020, the total economic impact of GHSU is estimated to generate $11.8 billion in the Georgia Economy. Total employment generated by GHSU operations, impacts to affiliated healthcare providers, industry, and workforce is expected to grow to 72,640 jobs by 2020.

Operational Impact: THE ANNUAL ECONOMIC, EMPLOYMENT, AND GOVERNMENT REVENUE IMPACT OF GEORGIA HEALTH SCIENCES UNIVERSITY’S OPERATIONS ON THE STATE OF GEORGIA  In 2010, GHSU3 had a total annual statewide economic impact of over $2.1 billion, supporting approximately 13,802 full‐time jobs and generating over $101 million in government revenue.  By 2020, Tripp Umbach estimates that the operations of GHSU will have a total annual statewide economic impact of approximately $2.8 billion, support 19,378 jobs and generate more than $142 million in government revenue.4

3 This report includes the economic impact of MCG Health System Inc. (governs MCG Health Inc. and the Physicians Practice Group) as part of the institution’s operational impact but does not include the economic impact of University Hospital and other teaching hospitals throughout the state where MCG places students or residents. 4 Does not include local government revenue, which is in addition to statewide totals.

 In 2010, more than $93 million was generated in the Georgia economy from out‐ of‐state visitors to GHSU5. This number includes spending by out‐of‐state patients, patient visitors, visitors to physicians, students, faculty and staff and vendors.

 Tripp Umbach estimates that by 2020, approximately $280 million will be generated in the Georgia economy from out‐of‐state visitors to GHSU.

Affiliated Healthcare Providers Impact: THE CURRENT AND FUTURE EXPANSION OF GRADUATE MEDICAL EDUCATION PROGRAMS, CLINICAL RESEARCH, AND HEALTHCARE CLINICAL ACTIVITY AT AFFILIATED HOSPITALS6 AND HEALTHCARE PROVIDERS ATTRACTS MILLIONS OF FRESH DOLLARS TO THE STATE OF GEORGIA ECONOMY  Academic and research programs at GHSU serves as a catalyst with affiliated hospitals and healthcare providers throughout the state, leading to the expansion of graduate medical education, basic science and clinical research, and additional sub‐specialty programs. For the purposes of this report, Tripp Umbach estimates that 5% of the total statewide economic, employment and government revenue impacts of non‐owned affiliated hospitals and other healthcare providers are attributable to GHSU7.

 In 2010, the economic impact of GHSU’s programs and services within affiliated hospitals and other healthcare providers had a total annual statewide economic impact of over $681 million, supporting approximately 4,544 full‐time jobs and generating over $34.1 million in government revenue.

 In 2020, Tripp Umbach estimates the economic impact of GHSU’s programs and services within affiliated hospitals and other healthcare providers had a total annual statewide economic impact of over $920.2 million, supporting approximately 6,134 5

Please refer to Appendix C for detailed out‐of‐state spending data for 2010.

6 Impacts related to MCG Health System Inc. are not included as “affiliated healthcare providers” but are included

in the operational impact numbers. 7 According to the Georgia Hospital Association the total economic impact of the 116 hospitals was $33 billion in

2009. The average hospital has an economic impact of $284.5 million. Tripp Umbach estimates that training programs and residency programs are responsible for 5% of a teaching hospitals total economic impact. Based on a conservative estimate of 5% of the total value, MCG generates $14 million annually in the state's economy at each hospital where they have medical students and or residents. Currently MCG has medical students at 48 hospitals throughout Georgia (medical students are trained at 112 total sites).

full‐time high‐paying jobs and generating over $46.0 million in government revenue.

 GHSU plays a significant role in the state’s healthcare safetynet through current and future partnerships with local health systems, research institutes, clinics and other collaborators. Students and faculty provide thousands of hours of clinical care each year, much of it free or at a reduced cost in clinics serving low‐income patients.  The involvement of academic partners on the GHSU campus and regional campuses with local health systems not only provides a necessary teaching environment, but also high‐quality care to those who could not afford it at other places – improving quality and outcomes throughout surrounding rural and urban communities in the State of Georgia.

Industry Impacts: BIOMEDICAL RESEARCH AT GEORGIA HEALTH SCIENCES UNIVERSITY DRIVES THE DEVELOPMENT OF NEW COMPANIES AND STRENGTHENS EXISTING COMPANIES STATEWIDE

 In 2010, the economic impact attributable to commercial applications, start‐up companies, attraction of new companies to the State of Georgia economy, and growth within existing Georgia‐based companies had a total annual statewide economic impact of over $200 million, supporting approximately 1,332 full‐time jobs and generating over $10 million in government revenue.

 In 2020, Tripp Umbach estimates the economic impact attributable to commercial applications, start‐up companies, attraction of new companies to the State of Georgia economy, and growth within existing Georgia‐based companies is estimated to have a total annual statewide economic impact of over $445 million, supporting approximately 3,472 full‐time jobs and generating over $22 million in government revenue.

Workforce Impacts: CURRENT AND FUTURE HEALTHCARE PROFESSIONALS EDUCATED AT GEORGIA HEALTH SCIENCES UNIVERSITY IN THE STATE OF GEORGIA TRANSFORM HEALTHCARE DELIVERY AND SAVE MILLIONS IN HEALTHCARE COSTS  Tripp Umbach estimates that Medical College of Georgia graduates8 who practice in the State of Georgia generated $5.3 billion in 2010 and will generate an additional $2.3 billion annually in the region’s economy by 20209, resulting in a total economic impact related to physician workforce of $7.6 billion.  In 2010, Medical College of Georgia graduates who practice in Georgia support more than 30,285 full‐time jobs statewide. By 2020, total statewide employment generated by Medical College of Georgia graduates practicing in Georgia is estimated to be 43,656.

 Tripp Umbach estimates that by 2020, 180 Medical College of Georgia graduates who remain to practice medicine in the state will generate an annual economic impact of $293 million will generate sustainable employment for 1,950 citizens each year in the State of Georgia and will generate nearly $14.7 million in additional government revenue.

NATIONAL STUDIES SHOW THAT THE combination of UME and GME in the same region has the greatest impact on creating and keeping future workforce. WHEN A YOUNG PERSON GRADUATES FROM HIGH SCHOOL, COLLEGE, MEDICAL SCHOOL AND COMPLETES A RESIDENCY IN THE SAME REGION/STATE his or

her chances to stay to practice medicine where they complete residency training is more than 70%...

All numbers presented in this report are based on Medical College of Georgia graduates (MD) and not on graduates from residency programs, which include students who completed medical school at other medical schools either in Georgia or out‐of‐state. The total workforce impact attributable to Medical College of Georgia is actually higher than reported as the Medical College of Georgia attracts and graduates residents from outside of Georgia who ultimately remain in the state to practice. 9 Tripp Umbach estimates from national benchmarks that by 2020 60% of all graduates from Medical College of Georgia’s campuses will practice medicine in the State of Georgia. At projected capacity of 300 students entering each cohort, this means 180 students each year will stay in the State of Georgia.

 Existing programs in nursing, allied health, and dentistry also graduate thousands of new healthcare professionals each year to serve the region and the state. In addition to the economic impact of physician graduates; Allied Health, Nursing, and Dentistry graduates working statewide had an additional economic impact of $2.5 billion in 2010.

Each Primary Care Physician within an Underserved Area Generates on average a $3.6M Economic Impact on the Region

Each Physician who Stays in a Community Generates $1.3M in Economic Impact on the Region

Each Physician’s Practice within the Community on Average Creates an Additional 6‐7 Jobs

Each Physician’s Practice on Average Generates $300,000 in Regional Tax Revenue

 An important aspect of the economic impact of a medical school is the annual impact that graduates have on the economy as they establish medical practices, specifically as a primary care physician within an underserved area. Each graduate who provides primary care services in rural and/or inner‐city underserved areas within the State of Georgia will save the state $3.6 million per year in avoided healthcare costs. Tripp Umbach estimates that by 2020, a total of 45 physicians each year graduating from the Medical College of Georgia programs will be providing primary care services in underserved communities throughout the State of

Georgia, thereby saving communities in Georgia an estimated $162 million each year in unnecessary medical costs.10

State of Georgia Economic Impact Findings of Georgia Health Sciences University The total economic impact of GHSU has grown dramatically over the past 15 years (1995 and 2005 Economic Impact Data shown in red). In 2010 the total economic impact of GHSU on the State of Georgia is over $2.0 billion. By 2015 the total annual impact is projected to jump to over $2.4 billion. The total economic impact of the future GHSU in 2020 is expected to equal $2.8 billion per year (see Figure 1)11.

$2.8

$2.4

Figure 1

State of Georgia Total Economic Impact of the GHSU 1995, 2005, 2010, 2015 & 2020 (Direct and Indirect) (Shown in billions)

$2.0 $1.7

$1.4

$0 1995

2005

2010

2015

2020

Tripp Umbach’s model assumes that 15% (national average approximately 3%) of the 300 graduates each year will be engaged in the provision of primary care in underserved areas based on data provided by Medical College of Georgia. 11 Georgia Health Sciences University became official name of the once titled Medical College of Georgia on February 1st 2011.

State of Georgia Economic Impact of Georgia Health Sciences University – Breakout Georgia Health Sciences University statewide economic impact is best measured in four ways: 1. the statewide operations of a comprehensive health sciences university with multiple campuses, research, and clinical operations, 2. Industry development resulting from the commercialization of research conducted at GHSU and affiliated academic partners (i.e. University of Georgia), 3. Workforce impacts related to physician graduates who remain in Georgia after graduating to provide medical care and 4. Affiliated Healthcare Providers where training is provided for GHSU students and residents.

2010 Impact (Shown in billions) $0.200

Operations

$0.681 $2.10

Physician Workforce $5.30

Industry

Chart 1 GHSU Operations, Industry, Physician Workforce, and Affiliated Healthcare Providers Statewide Impacts 2010 (Direct and Indirect) (Shown in billions)

Affiliated Healthcare Providers

2020 Impact (Shown in billions)

Chart 2

GHSU Operations, Industry, Physician Workforce, and Affiliated Healthcare Providers Statewide Impacts 2020 (Direct and Indirect) (Shown in billions)

$0.445 $0.920

Operations $2.8

$7.6

Physician Workforce Industry Affiliated Healthcare Providers

State of Georgia Employment Impact of Georgia Health Sciences University In 2010, the total statewide impact of employment at Georgia Health Sciences University was 13,802 direct and indirect jobs. Tripp Umbach estimates the impact of employment generated by GHSU in 2015 is projected to be 16,148 jobs. In 2020, the total employment impact will be over 19,378 new direct and indirect jobs in the State of Georgia (see Figure 2).

20,000 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000

19,378

Total

Indirect

16,148

Direct

13,802 10,765

Figure 2

State of Georgia Total Employment Impact of GHSU 2010, 2015 & 2020 (Total, Direct and Indirect) (# of jobs)

8,971 7,668

7,177

6,134

8,613

2,000 0

2010

2015

2020

State of Georgia Employment Impact of Georgia Health Sciences University – Breakout

2010 Impact (Shown in # of jobs)

1,332 4,544

Operations 13,802

Physician Workforce

30,285

Industry Affiliated Healthcare Providers

Chart 3

GHSU Operations, Industry, Physician Workforce, and Affiliated Healthcare Providers Statewide Employment Impact 2010 (Direct and Indirect) (Shown in # of jobs)

2020 Impact (Shown in # of jobs)

Chart 4 GHSU Operations, Industry, Physician Workforce, and Affiliated Physician Healthcare Providers Statewide Employment Impact 2020 (Direct and Indirect) (Shown in # of jobs)

3,472

6,134

Operations 19,378

Physician Workforce 43,656

Industry

Affiliated Healthcare Providers

State of Georgia Government Revenue Impact of Georgia Health Sciences University In order to quantify the financial returns to the State of Georgia, the models include a government revenue impact component, which calculates the total state tax revenue generated by Georgia Health Sciences University. In 2010, approximately $101.8 million in tax revenue is generated for the State of Georgia. Tripp Umbach projects the state will receive $119.1 million in state tax revenues in 2015, and by 2020 annual tax revenue will reach $142.9 million12 (see Figure 3). For every dollar received by Georgia Health Sciences University from the State of Georgia, the operations of the institution generated $11.73 for the state’s economy.

$160 $140 $120

$142.9

$119.1 $101.8

Figure 3

State of Georgia Total Government Revenue Impact of the GHSU 2010, 2015 & 2020 (Total, Direct and Indirect)

$100 $80 $60

$40

$20

$0 2010

2015

2020

12 This represents the total tax payments to the State of Georgia, directly and indirectly generated by GHSU. Taxes generated by the project for local units of government are not included in this number.

State of Georgia Government Revenue Impact of Georgia Health Sciences University – Breakout

2010 Impact (Shown in Millions) $10.0

$34.1

Operations $101.8

Physician Workforce $265.0

Industry

Chart 5

GHSU Operations, Industry, Physician Workforce, and Affiliated Healthcare Providers Statewide Government Revenue Impact 2010 (Direct and Indirect) (Shown in millions)

Affiliated Healthcare Providers

Chart 6 GHSU Operations, Industry, Physician Workforce, and Affiliated Healthcare Providers Statewide Government Revenue Impact 2020 (Direct and Indirect) (Shown in millions)

2020 Impact (Shown in Millions) $22

$46

Operations $142

$380

Physician Workforce

Industry

Affiliated Healthcare Providers

Physician Graduates who Practice in the State of Georgia It is important to note that the economic, employment, and government revenue impacts related to the Medical College of Georgia graduates is in addition to operational impacts presented in earlier sections of this report. The table below presents the impact that is brought to the State of Georgia because of Medical College of Georgia physician graduates who live and practice in Georgia. An important aspect of the economic impact of a medical school is the annual impact that physician graduates have on the economy as they establish medical practices. Tripp Umbach estimates that every physician who practices medicine in Georgia generates approximately $1.3 million annually in total economic impact to the state’s economy (directly and indirectly). In 2010, the Medical College of Georgia most recent graduates who completed residency and began practicing medicine in Georgia generated $95 million in total economic impact in 2010. (Note: The economic impact of all 4,086 Medical College of Georgia graduates practicing in the State of Georgia in 2010 equaled $5.3 billion). State of Georgia Impact Added Annually with Each Graduating Class

Economic Impacts (in millions) MCG Graduates who practice in the State of Georgia Employment Impacts (# of jobs) MCG Graduates who practice in the State of Georgia Government Revenue (in millions) MCG Graduates who practice in the State of Georgia

2010

2015

2020

$95

$182

$293

2010

2015

2020

650

1,250

1,950

2010

2015

2020

$4.8

$9.1

$14.7

Impact of Growth in Research and Bioscience Industry on the State of Georgia In 2010, Georgia Health Sciences University attracted over $100 million in annual research revenue from outside the state of Georgia, representing the re‐circulation of fresh dollars into the Georgia economy, with more than $63 million in funding from sources outside of the state of Georgia came from the National Institutes of Health (NIH). Tripp Umbach’s analysis shows that in 2010 the total economic impact of research related activities at Georgia Health Sciences University equaled $230 million and supports more than 1,533 jobs in Georgia. Tripp Umbach estimates that research conducted at GHSU over the past 10 years has led to approximately $440 million in healthcare cost savings to the State of Georgia. Tripp Umbach estimates that the total annual economic impact attributable to commercial applications, start‐up companies, attraction of new companies to the State of Georgia’s economy, and growth within existing Georgia‐based companies is $200 million in 2010, rising to $332 million annually in 2015 and $445 million annually by 2020 (see Figure 4).

$445

$450

$332

$400

Figure 4

$350 $300 $250

State of Georgia Economic Impact Related to Research & Bioscience Industry of GHSU 2010, 2015 and 2020 (Direct and Indirect) (Shown in millions)

$200

$200 $150 $100 $50 $0 2010

2015

2020

State of Georgia Current and Projected Employment Impact of Research and Bioscience Industry Tripp Umbach estimates that total created and sustained employment within the State of Georgia attributable to commercial applications, start‐up companies, attraction of new companies to the state, and growth within existing Georgia‐based companies, is approximately 1,332 jobs in 2010. By 2015, Tripp Umbach projects that 2,213 jobs will be created and 2,967 in the state by 2020 (see Figure 5). It is important to note that these numbers are in addition to operational employment numbers presented in earlier sections of this report.

Figure 5

5,000

2,967

4,000

2,213

3,000

1,332

2,000 1,000

State of Georgia Employment Impact Related to Research & Bioscience Industry of GHSU 2010, 2015 and 2020 (Direct and Indirect) (# of jobs)

0 2010

2015

2020

State of Georgia Current and Projected Government Revenue Impact Related to Research and Bioscience Industry Current government revenue generated as a result of commercial applications, start‐up companies, attraction of new companies to the region, and growth within existing Georgia‐ based companies is $10 million annually in 2010, over $16 million by 2015 and $22 million annually by 2020 (see Figure 6). It is important to note that these numbers are in addition to government revenue from operations presented in earlier sections of this report.

$22

$25

$20

State of Georgia Government Revenue Impact Related to Research & Bioscience Industry of GHSU 2010, 2015 and 2020 (Direct and Indirect) (Shown in millions)

$10

$15

Figure 6

$16

$10

$5 $0 2010

2015

2020

Conclusion Georgia Health Sciences University is a major driver of the Georgia economy and has the opportunity to add billions of dollars to the state’s economy over the next ten years. Expanding the impact of Georgia Health Sciences University requires a commitment to health sciences education at all levels through expanded statewide partnerships. Although Georgia Health Sciences University has a long history of providing education and training to medical and health professional students, the State of Georgia continues to have a physician and health professional shortage and much work still remains. With the development of a new four‐year medical school campus in Athens, two year campus expansions in Albany, GA and Savannah, GA and potential future campuses in other regions of the state such as Rome, GA, GHSU is well on its way to developing a future workforce and healthcare economy that will benefit all Georgians. Expanding residency programs in the State of Georgia will be an important physician workforce development strategy as additional residency positions will need to be developed to allow placement for future medical graduates. The current and future expanded GHSU has the opportunity to measurably improve the health status of the region and state through the expansion of innovative programs that connect a wide range of healthcare providers, public health agencies and other partners in creating healthier people and communities throughout the local, regional and state economies. Decisions made today will lead to measureable improvements in healthcare access, quality, and sustainable economic impact.

Appendix A: Tripp Umbach Qualifications Tripp Umbach is a national leader in conducting feasibility analysis / economic impact studies and consultation services for leading academic medical campuses and for new or expanded medical schools. The firm has provided consultation and economic impact analysis services to 18 new or expanded medical schools over the past six years. Tripp Umbach has previously conducted an economic impact study for GHSU (study completed in 2007) and was involved with the medical school feasibility study for their expansion to the Athens campus. Since 1995, Tripp Umbach has completed four national studies measuring the economic impact of all 130 medical schools and more than 400 teaching hospitals for the Association of American Medical Colleges (AAMC) making Tripp Umbach the most qualified firm to assess the feasibility and economic impact of a new or expanded medical school or hospital campus. In 2000, 50 of the top 100 academic medical centers ranked by U.S. News & World Report were active clients of Tripp Umbach. Since 1990, Tripp Umbach has completed individual studies for more than 75 academic medical centers.

Appendix B: Methodology Employed in the Economic Quantification Study Tripp Umbach has performed more than 100 economic impact studies for both academic institutions and large health care systems, including the Mayo Clinic Rochester, Mayo Clinic – Florida entities, UPMC Health System, and North Mississippi Health System. The methodology generally employed in these studies was originally derived from a set of research tools and techniques developed for the American Council on Education (ACE).13 The ACE‐based methodology employs linear cash flow modeling to track the flow of institution‐originated funds through a delineated spatial area. While this methodology is generally well suited to evaluate a hospital's impact on its local service area, it tends to be too limiting for a project with the complexity of a medical school with integrated systems or an entire academic health sciences campus. Based on previous economic impact studies performed for academic health centers in Pennsylvania and Virginia, Tripp Umbach recommended that the traditional model of economic impact for hospitals (see Figure 10), based on the ACE model, be modified for the purposes of this research. Figure 10 13 Caffery, John and Issacs, Herbert, “Estimating the Impact of a College or University on the Local Economy,”

American Council on Education, 1971.

The "traditional" model of hospital economic impact provides a good measure of the impact of hospital expenditures and their flow within an economy. However, the model does not account for the origination of hospital revenues, and thus counts the spending of revenues received by the hospital from in‐state sources. The traditional model counts some of the spending of dollars that already existed in the Georgia economy. The Tripp Umbach research team felt it important to distinguish the economic impact of the individual entities who will occupy GHSU that are attributable to funds brought into the state from out‐of‐state sources. The application of this "fresh dollar" model provides a first‐line measure of the initial direct expansion in the state economy caused by GHSU. The final model concept evolved into a hybrid model including a fresh‐dollar approach feeding into a traditional model which tracks in‐state spending. Thus the final model used for this research measures funds brought into the state together with the ultimate flow of these funds through the Georgia economy and the effect on economic expansion, job growth and enterprise development (see model below). The final methodology closely matches the impact study methodology recommended for individual medical schools by the Association of American Medical Colleges (AAMC). Input Model Out‐of‐state patients & their insurers

Out‐of‐state visitors

Out‐of‐state students

Visiting doctors & faculty

Out‐of‐state research funds

Out‐of‐state funds received by academic health center (gain for state economy

Hospital spending in the state (Start‐point for traditional model)

Economic impact outcomes for traditional model. Separted into figures for TEI & impact allocable to out‐of ‐state $

Tripp Umbach healthcare researchers worked closely with representatives from GHSU to acquire the primary data utilized in this study. Tripp Umbach utilized a forward‐linkage modeling methodology to measure the potential impact of the commercialization of research and related commercial spin‐offs in the State of Georgia. Traditional economic impact studies are based on direct spending and re‐spending within the economy (multiplier effect) driven from the institution itself. Forward‐linkage models measure the broader impacts that occur or may occur in the economy as a result of the research and development activities of an institution – beyond the traditional direct and indirect impacts. Examples of forward‐linkage impacts include new businesses based on academic research discoveries; academic intellectual property licensed to existing businesses for development and sponsored research relationships. Original research conducted by Tripp Umbach for the Mayo Clinic and the University of Minnesota was used as a starting point for customized analysis. The Mayo Clinic and University of Minnesota research involved the creation of a series of 36 customized economic impact models based upon numerous assumptions. The basic architecture of these models is the methodology most widely accepted within the industry. Due to the complexity of measuring the impact of biotechnology and medical research, Tripp Umbach researchers developed a series of customized economic impact models showing the economic, employment and government revenue impacts of both the recipient institutions and potential business spin‐offs in the calendar year 2015 and 2020. The linear cash flow models developed for this project represent annual, point‐in‐time economic impact projections. Economic projections for each scenario are based upon a specific and detailed set of assumptions. Each assumption is based upon secondary data research, primary research and Tripp Umbach industry expertise.14 For the purposes of this report, Tripp Umbach calculated both direct and indirect impacts for the current University and affiliates (2009) in the following benchmark years: 2015 and 2020. To calculate the economic impact of Georgia Health Sciences University and research commercialization in the state of Georgia, Tripp Umbach used a methodology derived from the original set of research tools and techniques developed for the American Council on Education (ACE) (see Appendix B for full overview of methodology). 14 Tripp Umbach is confident in the model construction and projections presented herein; however, shifts in the

overall economic climate in the state and nation and changes in state government policy toward biomedical science and medical research are not calculated or accounted for in this study. The projections presented in this study are based upon the state moving forward to make medical research and healthcare services an increasingly important industry sector in the State of Georgia.

Appendix C: Detailed Direct Economic Impact Findings of Georgia Health Sciences University’s Operations in 2010 THE DIRECT IMPACT WAS COMPRISED OF THE FOLLOWING IMPACT COMPONENTS: Direct spending for capital improvements, goods, supplies and services This category of impact includes the spending by Georgia Health Sciences University, including its many clinical, educational, and research partnerships throughout the State of Georgia for improvements to their facilities and capital equipment purchases. In addition, the category also includes the purchase of goods, services and supplies. These may include a broad range of purchases such as laundry services, food and beverage supplies, drugs, medical disposables, computer consulting, etc. GHSU, including its many clinical, educational, and research partnerships throughout the State of Georgia spending for capital improvements, goods, supplies, and services equaled $323,149,820 2010. Direct spending by staff While Georgia Health Sciences University staff spends substantial money on goods and services, one of their biggest benefits to the economy is their direct payroll. GHSU has a payroll and benefits obligation to staff that generates significant direct and indirect impacts through staff spending. Spending by staff employed by GHSU, partnerships and its affiliate organizations (Medical College of Georgia, Other Non‐COM components of GHSU, MCG Health System Inc. and the Physicians Practice Group) equaled $245,911,204 in 2010. Direct spending by employed physicians and faculty As with payroll to general staff, the pay provided to physicians directly employed with Georgia Health Sciences University has a substantial positive impact on the economy through physician spending. Spending by employed physicians equaled $84,280,651 in 2010. Direct spending by residents, medical and health sciences students Spending by residents and students for housing, food, supplies, entertainment, and other items and services comprise their direct impact on the State of Georgia’s economy. Only resident and student spending that is made off‐campus is included in the impact calculations. Spending by residents and students equaled $49,942,288 in 2010.

Direct spending, outside of Georgia Health Sciences University, partnerships and its affiliate organizations, by patients from out‐of‐state Spending by patients for medical services is not included in the direct impact. Only the spending of these patients (both inpatients and outpatients) outside of Georgia Health Sciences University, partnerships and its affiliate organizations is included. Spending outside of GHSU, partnerships and affiliate organizations by patients equaled $4,548,105 in 2010. Direct spending by out‐of‐state patient visitors Medical centers and teaching hospitals are substantial visitor destinations. Visitors come to see patients who are friends and family, and they create spending in the economy with these visits for accommodations, gifts, services and other items during their stay. Spending by out‐of‐state patient visitors equaled $10,256,441. Direct spending by visitors to staff, employed physicians, residents and students Georgia Health Sciences University, partnerships and its affiliate organization’s visitors visiting staff, employed physicians, residents, and students attract substantial numbers of out‐of‐state visitors. Spending by all of these visitors equaled $78,879,144 in 2010.

Appendix D: Definition of Terms TOTAL ECONOMIC IMPACT

TOTAL STATE BUSINESS VOLUME

MULTIPLIER EFFECT

INDIRECT TAX PAYMENTS

DIRECT EMPLOYMENT INDIRECT EMPLOYMENT

The total economic impact of an institution includes both the direct economic impact and the indirect economic impact generated in the economy as a result of the direct impact. Direct impact includes items such as institutional spending, employee spending, and spending by out‐of‐area visitors to the institution. Indirect economic impact, also known as the multiplier effect, includes the re‐spending of dollars within the local economy. Total sales receipts generated within a given geographic area of the State of Georgia. Business volume includes wholesale, retail, service sector spending as well as value added in the manufacturing process. The multiplier effect is the additional economic impact created as a result of the institution’s direct economic impact. Local companies that provide goods and services to an institution increase their purchasing, creating a multiplier. Government revenue that is collected by governmental units in addition to those paid direct by an institution, including taxes paid directly by employees of the institution, visitors to the institution, and vendors who sell products to the institution. Total employees based on Full‐Time Equivalents (FTEs). Indirect employment is the additional jobs created as a result of the institution’s economic impact. Local companies that provide goods and services to an institution increase their number of employees as purchasing increases, creating an employment multiplier.

Appendix 15: Overview of the Environment

Appendix 15: Overview of the Environment Current State of Public Health in Georgia Diseases and injury have a substantial negative impact on the lives of individual Georgians, their families, and their communities. The physical, emotional, and financial consequences of chronic diseases and injuries are extensive and, in many cases, are enduring. The United States spends more on health care than any other nation in the world, yet it lags behind many developed nations in important health measures. Compared with other developed nations, the United States has relatively low life expectancy, high infant mortality rates, a high prevalence of HIV/AIDS and persistent health inequities. In Georgia, the top five leading causes of death overall are 1) heart disease, 2) cancer, 3) stroke, 4) injury, and 5) chronic lung disease. Among African‐Americans, HIV replaces chronic lung disease as the fifth leading cause of death. Among those aged 34 years or less in Georgia, injury, homicide, suicide, and HIV are major causes of death.     

Georgia has a higher age‐adjusted mortality rate of stroke and major cardiovascular diseases and higher age‐adjusted prevalence of hospitalization for stroke and hospitalization for congestive heart failure for persons receiving Medicare aged 65 years or more. The prevalence of obesity in Georgia is greater than the nation overall. The prevalence of diabetes and other indicators of overall health, such as percentage of citizens aged 65 years or more with all teeth lost, is greater than that seen overall in the US. The percentage of Georgian women who delivered an infant who received early and adequate prenatal care is significantly below the national average and markedly below the Healthy People 2010 goal. The percentage of low birth weight babies is greater for all races than the Healthy People 2010 goal, but African Americans in Georgia have nearly twice the percentage as do whites.

While, according to America’s Health Rankings, Georgia improved in overall rankings from 43rd in 2009 to 36th in 2010, it still lags far behind on important measures such as infectious disease (47th), infant mortality (41st), cardiovascular deaths (40th), and rate of uninsured residents (44th). Health Professions Workforce: National and State Context For the past decade, the United States has experienced worsening health professions workforce shortages with need outpacing production. Analysts now are projecting a nationwide shortage of almost 100,000 physicians, as many as one million nurses, and 250,000 other public health professionals by 2020. Similar gaps between production of health professionals and need exist in the State of Georgia. For example, the size and distribution of Georgia’s dental workforce (which includes dentists, dental hygienists, dental assistants, and dental laboratory technicians) is not meeting population demands. As of 2009, Georgia had 56.2 dentists per 100,000 population, which is 30 percent below the national rate of 80.7/100,000. Georgia ranks 48th in the US and would need 2,400 additional dentists to reach the national rate. Within Georgia, maldistribution is an issue, as well, resulting in challenges in access to care.   

Nearly 1 in 7 Georgia counties has no dentist 11 Georgia counties have only 1 dentist 99 counties have received some form of federal designation as a dental professional shortage area

The table below illustrates the deficit of disciplines annually adjusted after replacement: Discipline Physician Dentist Dental Hygienist Physician Assistant Respiratory Therapist Physical Therapist (Masters and Doctorate) Occupational Therapist Medical Lab Sciences Technologist Registered Nurses Advanced Practice Nurses Nurse Anesthetists

Annual unmet need/8 yr total 112/896 85/680 98/784 30/240 47/376 42/336 25/200 80/640 462/3,696 1,020/8,160 54/432

Of particular concern are physician workforce shortages. The size of Georgia’s physician workforce falls below national per capita rates, with Georgia having only 80 percent the national capacity. Given that the nation is facing shortages as well (estimated shortfall of 90,000 by 2020), this suggests that Georgia’s shortages are at a higher proportion. Developing a physician workforce requires ‘priming the pump’ through enhanced medical student enrollment and increasing the availability of residency training. Medical education is comprised of two components ‐ undergraduate medical education (UME) and residency training (GME). Both UME and GME training are highly regulated with respective national accreditation bodies: the Liaison Committee on Medical Education (LCME) and the Accreditation Council for Graduate Medical Education (ACGME). These agencies regularly assess and approve educational programs based upon:  Their capacity to attract and enroll competitive trainees  The educational program  Educational milieu  Trainee feedback of educational content  Institutional commitment and resources Expansion of existing medical schools and/or creation of new medical schools are highly regulated by LCME. The expansion of medical student enrollment at GHSU has proceeded deliberately with step‐ wise LCME input, review, and approval contingent upon institutional commitment and resources. GME training and program development also requires evaluation of educational capacity, clinical volume, trainee experiences, and institutional academic milieu, particularly related to research productivity and scientific endeavors.

In 2009, the Association of American Medical Colleges (AAMC) called for a 30 PERCENT increase nationally in the enrollment of medical students into undergraduate training (the first phase of training) to become physicians. National approaches have included:  Expansion of medical student class sizes at existing medical schools  Founding of new medical schools  Expansion of existing medical school capacity through the regional campus model (several approaches) Each of the medical schools in Georgia – private and public – have been responsive in increasing medical student enrollment such that the increased number of medical students has now actually outstripped the availability of first year residency positions to support the entry of these new trainee doctors into the second phase (residency) specialist training of their career. The physician shortage will undeniably create a greater demand and dependency on masters and doctorally trained health professionals. This dependency will increase demand for advanced care nurses, master’s and doctorally educated allied health sciences professionals, such as physician assistants, physical therapists, occupational therapists, and others – commonly referred to as physician extenders. Over the past decade, GHSU has advanced its programmatic array toward the national and state needs in the graduate degree (masters and doctoral) array – but this causes additional pressures on the educational enterprise.  The faculty and facilities requirements for a more advanced degree program generally escalate due to the length of the program (credit hours) and complexities of the curriculum.  The more terminal rank faculty required for higher degree levels are usually more difficult and costly to recruit.  The programs also generally require a lower student to faculty ratio. Another pressure on Georgia’s health workforce is that a significant percent of the existing workforce is “graying,” a situation that perhaps is most critical in nursing with the average age of the nursing workforce climbing at 46.8 years with many nurses anticipated to retire in the next decade. Clearly, the most educated faculty and nurse leaders are nearing the end of their careers. For physicians, the Association of American Medical Colleges predicted that of the 800,000 doctors currently in practice across the nation, about 250,000 would retire in the next ten years. This dilemma coupled with demand outpacing new supply, any attrition of the workforce will offer profound negative impact. Accrediting agencies (notably SACS) require faculty to have terminal rank, usually doctorates, in the degree programs they Health care policy leaders expect AHCs to: teach. Recognizing a majority of the current faculty workforce is within ten years of • Be the leaders at the forefront of health care retirement, it is crucial the state achieve • Accept the coming changes to the system the demand in creating academic faculty. • Find ways to be more cost effective At present, Georgia’s approach to ensuring an appropriately trained health professions • Develop new models of care workforce is relatively fragmented, guided by institution‐specific plans that lack state‐ • Be the health care players who take the helm and level oversight. Thirty‐two University institutionalize the coming changes first System of Georgia institutions offer more than 200 health professions programs. The Technical College System of Georgia educates and trains health professionals as do the state’s private colleges and universities and proprietary institutions. No coordination exists among these entities to ensure that the right kinds of health providers are being produced in the right numbers for the areas of the state with the most pressing need. This uncoordinated approach dilutes funding and creates a competitive versus a cooperative environment.

Health Care Reform Although the long‐term viability of specific elements of the health care reform bill – Patient Protection and Affordable Care Act – is still debated, it is clear that PPACA still represents the largest change in health care in 40 years. The plan is expected to roll out over several years and contains elements that affect the different segments of the population in different ways over time. Leading the way for Georgia and GHSU, President Ricardo Azziz is among the group of leaders on a gubernatorial committee examining the development of a Health Insurance Exchange and Health Information Exchange for Georgia. Consideration of the emergent health care arena is critical in formulating GHSU’s strategy for the future. Moreover, AHCs are well positioned to advance health care reform. In Georgia, the capacity for access to health care professionals post‐health care reform is a concern. For example:     

Georgia is ranked 9th in the nation in population, but 44th in physicians per capita Approximately 15 percent of Georgia’s population – more than 1.4 million citizens – currently live in an area with a significant deficit in primary care health professionals More than 20 percent of adults in Georgia do not have a usual source of care More than 40 percent of children do not have a medical home An additional 20% of Georgia residents will be newly insured and seeking care post‐reform

Expectations of health care reform include:      

Program coordination between hospitals to eliminate duplication of high cost expensive services Efficiencies to lower costs and improve quality, benefiting patients Consumer decisions based on best price and best clinical results New models for innovative health care delivery (include sharing the risk with hospitals and/or physicians, bundling payments, Accountable Care Organizations) Withholding payments for poor quality providers Incentives to high quality providers

It is also anticipated that health care professionals will be more closely aligned with hospitals post‐ reform. Collaboration of all players in health care, including patients, physicians, hospitals, communities, and employers is the new order of the day. Following a major integration at both structural and functional levels of the enterprise, GHSU is poised to respond to the challenges and opportunities presented by health care reform. The emergent tertiary and quaternary outreach strategy, coupled with a more collaborative stance with other local and regional health care providers, will position GHSU to optimize the health care leadership role of an academic health center. The New Normal The Great Recession hit Georgia harder than many states. We were first in bank closures, sixth in home foreclosures, and one of the states with a persistently high unemployment rate. Economists agree about few things, but they have consensus on what is critical to digging out of the economic trench that offers no end in sight: economic growth in the 21st Century is tied to our ability to adapt to globalization and is fueled by knowledge‐driven, science‐based, technology‐enabled industries and locations. The components to make that happen are what the GHSU enterprise is – knowledge shared by teaching, discovered through research, and applied through clinical and economic development measures that help industries grow and generate good jobs for Georgians. According to renowned Georgia economist, Dr. Don Ratazcak, who Business Week has cited among the nation’s most accurate economists, Georgia has two sectors experiencing expansion: manufacturing and health care.

The highest paid manufacturing jobs are life science‐based, Georgia has two sectors stemming from research university innovations that industry is experiencing expansion… quickly shifting expenses to and where Georgia average wages manufacturing and health care command more than $70,000 per year per worker. Healthcare demands and workforce needs are soaring due to market demographics. Consequently, GHSU graduates are immediately and fully employed making excellent salaries. However, the State of Georgia budget is struggling under the burden of accelerating health care costs, now consuming $1 of every $6 dollars spent, thereby reducing funds needed for other infrastructure demands such as education, transportation and quality of life factors. In light of Georgia’s position as the 2nd most obese state in the world’s most obese nation, our financial picture gets more distressing. The Georgia Department of Community Health presents one staggering projection: Georgia’s childhood obesity rates, if unchecked between 2011 and 2025, will result in a chronic disease cost of $19.5 billion annually for our state – an amount in excess of the state’s entire FY2012 budget. Other challenges in the area of science and technology:

 In overall science and technology rankings, Georgia is 25th, middle of the pack, down from 15th in 2002.

 Georgia’s 2010 Research and Development Inputs Composite Index ranking was 34th among all

states, down from our 2002 rank of 25th.  Georgia’s Risk Capital and Entrepreneurial Infrastructure rank fell to 15th from 7th between 2002 and 2010. And, we are losing the talent wars for technology and science work force. In 2002, Georgia ranked 12th but by 2010 we lost significant competitive advantage as 29th among 50 states. But crisis conditions present strategic opportunities for collaborations, and that belief forms the basis of the Georgia Health Sciences University’s eight‐year vision.

Appendix 16: Creating a Biotech Park

Appendix 16: Creating a Biotech Park Creating a Biotech Park A Proposal for the Golf and Gardens Property in Augusta Why Create a Biotech Park? Biotech parks are a type of industrial parks that specialize in biotechnology and scientific research on a business footing. Biotech parks can serve as economic engines for a community, particularly when the community has the appropriate biomedical research infrastructure in place. As home to Georgia Health Sciences University and a thriving medical community, Augusta is well positioned for this type of development. Affiliating with a university focused on biomedical research is a critical success factor in these endeavors as the university brings the necessary research infrastructure and intellectual and human capital needed to attract biotech businesses. Successful Ventures The Virginia Biotechnology Research Park at Virginia Commonwealth University, the Science + Technology Park at Johns Hopkins University, and Worcester Polytechnic Institute's Gateway Park are examples of growing centers of research, innovation and commerce – initiatives that are contributing to the economic health of the regions they serve.  The Virginia Biotechnology Research Park, for example, is home to 63 life science organizations, including VCU research institutes, state and federal laboratories, more than a dozen early and mid‐stage ventures, and multinational companies.  The 31‐acre Johns Hopkins facility provides life science firms, whether early stage or mature, with a unique opportunity for collaboration and direct access to the Johns Hopkins medical and research complex, its facilities, and its scientists ‐ as well as an entry point into the U.S. life science market.  WPI’s Gateway Park was designated by the Commonwealth of Massachusetts as the anchor for the state's first Growth District, a new initiative to accelerate job creation in locations that are primed and ready for development. Augusta’s neighboring (and much smaller) city, Aiken, South Carolina, recognized the significant impact that the biotech industry can have for communities and developed the Warner Savannah River Research Campus, a 422‐acre county‐owned site designed to host a wide range of technology‐based business ventures. The Property Originally known as the Georgia Golf Hall of Fame Botanical Gardens, the ‘Golf and Gardens’ property is a 17‐acre parcel located in downtown Augusta along the Savannah River. Once home to pristine display gardens and world‐class golfers, funding for the facility was

discontinued in 2007 – and the once grand gardens fell into disrepair. The property is owned by the state of Georgia but stands fallow and unused. Georgia Health Sciences University as the Anchor The university proposes to construct a 165,000 square foot, $80 million clinical translational research/combined use facility on five acres of the 17‐acre Golf and Gardens Property. This facility would house up to 100 researchers, with associated support staff. We project that adding 100 new researchers in this location would increase GHSU’s extramural funding by $40 to 50 million, create 800 to 1,000 new jobs locally, generate $4 to 5 million in state and local tax revenues, and ultimately produce more than 100 new patents and five to 10 spinoff companies. The balance of the property could be placed under the control of the state’s Department of Economic Development or other appropriate state agency with whom GHSU would partner in helping to draw new, related businesses to the site. GHSU has no pressing need for additional land but is interested in working to promote and grow the economy of the city and region while enhancing its research capacity, particularly with in partnership with industry. Developing the Golf and Gardens property as a biotechnology destination with GHSU serving as a catalyst to help fuel investment would benefit multiple parties – the state, the city, the region, and the people who call this community home. The Golf and Gardens property, situated on the banks of the Savannah, is in a desirable location – and potential uses discussed have included a baseball stadium. The development of a clinical translational science research facility on this site would aid GHSU in attracting nationally and internationally recognized researchers with robust portfolios, add to university’s already substantial economic impact, and help the city attract the types of businesses that can help the economy grow further. Fiscal Challenges This is an exciting opportunity with the potential of reaping significant financial return for the region. Partnership will be key to its successful development. GHSU, like all state‐assisted entities, faces resource challenges. The new facility would have to be constructed through a Public Private Venture mechanism, with financing through the Georgia Health Sciences Health System and supported in part by indirect cost recovery funds and other internal resources. In order for GHSU to construct a facility on this site, five acres of the parcel would have to be transferred from the state to the University System of Georgia Board of Regents at no cost. Additionally, GHSU would require tangible financial support from the state and/or city to undertake this project, support that could come in the form of an agreement to share revenues generated from property leases, state bond support to lessen public‐private borrowing and debt service costs, and/or a direct financial commitment from the city of Augusta that could be used to defray or lessen costs. In exchange for this support, GHSU would commit to work closely with Georgia’s Department of Economic Development to develop complimentary business activity at the site.

Appendix 17: AACI Statesâ&#x20AC;&#x2122; Investment in Cancer Research

Statesâ&#x20AC;&#x2122; Investments in Cancer Research A Survey Conducted by the Association of American Cancer Institutes (AACI)

Survey Methods ´

Survey Focused on State Funding for Cancer Centers « Direct

appropriations to AACI centers (or parent institutions)) « Tobacco excise tax dollars supporting cancer research at AACI centers « Tobacco settlement dollars supporting cancer research at AACI centers

Responses C R Collected ll t d June-July J J l 2008 ´ 64 of 92 Cancer Centers Responded ´ Survey Built in Collaboration with CCAF ´

Responding Centers Centers’ Characteristics ´

NCI Designation NCI-Designation ´ 48

NCI-Designated Centers ´ 16 Emerging Centers ´

Matrix/Freestanding ´ 51

Matrix M ti C Centers t ´ 13 Free-standing Centers

State Funding for Cancer Centers

State Funding for Cancer Centers Cancer Centers that areâ&#x20AC;Ś

Number of Responses

Percent of Responses

Part of a public (state-owned) institution that receives annual state funding

45%

An independent public (state-related) entity that directly receives annual state funding

14%

An independent private entity that directly receives annual state funding

11%

An entity that does not receive annual state fundingg

30%

Canc cer Cen nters at Publiic Unive ersities s

State Funding for Cancer Centers 16

2 1 Less than 1 to 2.49% 1%

2.5 to 5%

Greater than 5%

Percent of Parent Institutionâ&#x20AC;&#x2122;s State Funding Allocated to the Cancer Center

n=20

State Funding for Cancer Centers

Can ncer Cen nters

25 20

15 10

0 Less than $5 million

$5-10 million

$10-15 million

$15-20 million

$20-25 More than million $25 million

Mean=$12.8 million, Median = $2.4 million n=30

State Funding for Cancer Centers Less than $5 Million 7 6 Can ncer Cen nters

7 6

3 2 1 0 Less than $1 million

$1-2 million

$2-3 million

n=22

$3-4 million

$4-5 million

Allocation of State Funding for Cancer Centers

State Tobacco Excise Tax Dollars Allocated to AACI Cancer Centers

Tobacco Excise Tax Dollars Survey Responses… Cancer Centers Reporting

Number of States Represented

States of responding Centers Taxing Tobacco Products

Cancer Centers Receiving a Portion of S State’s ’ Excise E i Tax T on TTobacco b P Products d

Tobacco Excise Tax Dollars Percent of Revenue Received from Stateâ&#x20AC;&#x2122;s Excise Tax on Tobacco Products at Five Cancer Centers 20.0%

20.0%

15.0% 10.0% 5.0%

8.0% 4.4%

0.0%

3.6% 1.7% 1 7%

Cancer Research Center of Hawaii Louisiana Cancer H. Lee Moffitt Research Cancer Center & Consortium Research Institute

UNMC Eppley Cancer Center

Markey Cancer Center/University of Kentucky

State Tobacco Settlement Dollars Research Allocated to AACI Cancer Centers

Where Does the Tobacco Settlement $ Go? Program Areas Receiving State Tobacco Settlement Funding 40.0% 30.0% 20.0% 10.0% 0.0%

32.1% 28.8% 13 2% 13.2% 5.7% 5.4% 4.7% 3.8%

2.7%

1 5% 1.5% 1.5% 1 5%

N=46 states FY 2006, Source: U.S. Government Accountability Office

0.3%

Tobacco Settlement Dollars Survey Responsesâ&#x20AC;Ś Cancer Centers Reporting

Number of States Represented

Cancer Centers Receiving Funds from State Tobacco Settlement

Median Funding Mean Funding

$3 million $3.3 million

Tobacco Settlement Dollars Cancer Center Budget Categories pp byy Tobacco Settlement Fundingg Supported

Number of Cancer Centers

Operations

Recruitment

Research

Building Funds

Regional Cancer Control Activities

Other

n=13 cancer centers

State Comprehensive Cancer Control (CCC) Plans

Ca ancer Ce enters

Role of Cancer Center in Writing State CCC Plans

20 15

0 5 Very Active "Very Active"

How active a role did your cancer center play p y in writing g yyour stateâ&#x20AC;&#x2122;s CCC p plan?

n=48

1 "Not Active"

Cancer Centers and State CCC Plans Cancer Center Participation

Number of Cancer Centers

Implementation of the state CCC plan is a cancer center priority

Cancer Centers that have members involved in implementing selected sections of the plan

Cancer Centers that have members chairing committees and playing other key roles in the state CCC coalition

Cancer Centers that have members chairing the CCC coalition board

n=48 cancer centers

Cancer Centers and State CCC Plans Cancer Center Participation

Number of Cancer Centers

Cancer Centers that have contributed financial supportt to t the th state t t CCC plan l

Cancer Centers that have received state or CCC coalition funds to help implement the plan

Cancer Center Directors whose priorities are included in their stateâ&#x20AC;&#x2122;s CCC plan

n=48 cancer centers

Appendix 18: Physicians Practicing in Rural Locations

. . . . . Workforce Issues . . . . .

Factors That Influence Physicians to Practice in Rural Locations: A Review and Commentary Darra Ballance, MLIS, AHIP;1 Denise Kornegay, MSW;1 and Paul Evans, DO2

addressed? Are there ways to influence new physicians to consider rural practice? Is this just a health care policy issue? Fortunately, many other factors appear to influence physiciansâ&#x20AC;&#x2122; practice location decisions, especially rural practice locations. These factors fall into 5 general categories: (1) preparation for and recruitment by medical schools; (2) the medical school experience; (3) the residency experience; (4) recruitment of physicians to rural communities; and (5) retention of rural physicians. We searched the published literature in each of these 5 areas along the entire educational pipeline to learn what strategies strengthen studentsâ&#x20AC;&#x2122; and residentsâ&#x20AC;&#x2122; intentions to practice in rural areas, and how to retain physicians once they are located in such areas. A literature search of MEDLINE covered the years 1966 to 2008. MeSH headings used included: physicians; physicians, family; physicians, women; professional practice location; rural health services; rural health; career choice; education, premedical; medical education, undergraduate; medical schools; medically underserved area; and rural population. Only English-language articles and those most applicable to the United States were included. We focused on research on large groups, such as surveys of graduates from long-standing programs, and on articles that addressed gaps in the literature. Articles were grouped into the 5 categories listed above.

ABSTRACT: Rural populations remain underserved by physicians, despite various efforts by medical schools and other institutions/organizations to correct this disparity. We examined the literature on factors that influence rural practice location decisions by physicians to determine what opportunities exist along the entire educational pipeline to entice physicians to, and retain them in, rural areas. Results reported in the literature favor a multidisciplinary or multi-faceted approach that results in more residents and physicians locating their practices in rural areas. The need to define proven strategies is not the pressing issue; rather, the needs are to define the commitments necessary to implement proven strategies, as well as the will to make physician distribution a priority issue in medical education.

he shortage of physicians in rural areas of the United States remains a persistent problem. About 11% of all physicians treat the 20% of the US population that resides in rural areas.1 In February 2005, the Association of American Medical Colleges recommended that enrollment at medical schools be increased by 15% over the next 15 years. In response to this recommendation and the persistent need for more physicians, many medical schools have expanded their class sizes and several have developed satellite campuses.2,3 The decline in rural physician supply is becoming more severe. There are many factors contributing to this decline. More female physicians are entering the profession, with fewer women than men choosing rural practice.4,5 The number of graduates who choose careers in generalist medicine or family practice has also declined; these graduates make up a majority of physicians who decide on rural practice locations.6,7 Physicians from rural backgrounds are more likely than their urban counterparts to choose rural practice,8-10 but too few rural students are applying to medical schools to ameliorate the shortage.11 How should medical school educators approach this dilemma? In what ways can this growing gap in health care provision be C 2009 National Rural Health Association

Preparation for and Recruitment by Medical Schools. Many medical schools currently offer short

summer programs designed to increase academic competitiveness for high school and undergraduate students. These programs generally begin in high

1 Statewide

Area Health Education Centers Network, Medical College of Georgia, Augusta, Ga. 2 Georgia

Campus, Philadelphia College of Osteopathic Medicine, Suwanee, Ga. For further information, contact: Darra Ballance, Statewide AHEC Network, HT-2402, Medical College of Georgia, Augusta GA 30912; e-mail dballance@mcg.edu.

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school, and usually feature some combination of physician shadowing, hands-on activities, and classroom learning or tutoring. Many area health education centers (AHECs) offer such programs or coordinate them with academic medical centers. McKendall,8 Knopke,9 and Crump10 have reported on programs that expose rural high school students to health careers in their communities and provide tutoring. These programs have shown higher ACT scores after completion. When rural students are academically qualified, their subsequent admission to medical schools will likely result in the graduation of higher numbers of physicians who return to rural communities.12,13

practice location could be identified, 33% of graduates chose a rural practice location, more than 3 times the national average. The University of Washington created the WAMI program for medical students from Washington, Alaska, Montana, and Idaho. Phillips et al18 reported on the long-term effect of the program’s required family medicine rural clinical clerkship. The goal was to have at least 20% of each class enter family medicine, but when the first 6 graduating classes were studied in 1994, more than 30% of the graduates had entered family medicine residencies, and 57% of all graduates were still in family practice. The Physician Shortage Area Program (PSAP) at Jefferson Medical College in Pennsylvania is a special admissions program developed in 1974 to identify medical student applicants who would eventually practice family medicine in underserved areas.19 Qualified applicants are given high priority for the program only if they have lived in or have strong family ties to an area in or adjacent to a physician shortage area of Pennsylvania. Upon admission, students are required to take several family medicine clerkships. Rabinowitz found that these students are 5 times as likely as their peers to enter family medicine, and almost twice as likely to enter this specialty compared to non-PSAP students who entered Jefferson Medical College with the desire to become family physicians. The selective admissions component of the PSAP is the most important reason for its success.20,21 Replication of the PSAP program, or similar programs focused on rural outcomes, at all 125 US allopathic medical schools could result in 1,139 rural physicians annually if results were similar.21 Selective admissions policies that give preference to rural candidates do not result in the acceptance of unqualified applicants. Like the PSAP, the University of Missouri-Columbia School of Medicine studied its rural medical school applicants and determined that the school was able to maintain competitive admissions criteria while still admitting students who were most likely to choose rural practice.22 The Rural Medical Education Program (RMED) at the State University of New York’s (SUNY) Upstate Medical University has documented high numbers of physicians who chose rural practice locations.23 Students in the RMED program receive their clinical training in rural communities rather than on the SUNY Upstate campuses, spending 36 weeks under the guidance of a primary care preceptor, usually a rural family physician. Eighty-four percent said the program had helped them choose a rural practice location. To summarize, a combination of selective admissions and focused rural/generalist curricula may

Experiences During Medical School. We examined articles about schools with 2 types of programs: those with extended rural clerkships; and those with either selective admissions for family medicine/ primary care studies, or entirely separate educational tracks for primary care. Both types of programs have proven effective in maintaining and encouraging students’ interests in rural primary care. Blue et al14 described a 4-week rural primary care clerkship required for all third-year students at the Medical University of South Carolina. The students’ perceptions of rural practice became significantly more positive after completing the clerkship. Although these students had not yet completed residency and therefore did not have practice locations, other evidence shows that positive rural experiences during medical school can have a strong influence on practice location choices.15 In Colorado, Fryer et al16 studied an AHEC program that offered extramural rotations for medical students. More students who had experienced at least 1 extramural rotation listed primary care specialties than did students who had not participated. The authors noted that while there was initially some faculty reluctance to entrust clinical preparation of students to non-academicians, these students scored as high on the National Medical Board Examination for their specialties as had students who were taught or precepted in the university setting. The Appalachian Preceptorship at East Tennessee State University has offered a month-long medical school clerkship that has both a clinical component and a week of complementary classroom instruction.17 The program, in existence for over 20 years, is designed to increase retention in rural practice by emphasizing the attractive cultural and practical aspects of a rural community. Residency choices of the 164 participants who matched prior to 2005 indicated that 82% selected a primary care specialty. Of the former students whose Ballance, Kornegay and Evans

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be the best way to increase the number of medical school graduates who intend to practice in rural areas. Kassebaum and Szenas urged educators to focus their efforts on sustaining and increasing all students’ interest in generalist medicine and rural practice, regardless of rural or urban background,5 since the number of students with rural backgrounds is too small to make up for present and future shortages, even if all were to choose rural practices.

is practicing and the geographic area in which he or she (1) lived during pre-adulthood, (2) attended medical school, and (3) completed a residency.28 A good interpersonal match with future colleagues can be a strong indicator of a satisfactory practice location. If the physician has a partner or spouse, both must determine whether a community is a good fit for them.29 One study that surveyed graduates and current residents from 12 family practice residency programs in the western United States recommended certain strategies to assist rural communities in physician recruitment: create a diverse recruitment committee, plan the recruitment strategy carefully, identify prospects early and stay in touch during residency, make a good first impression, identify the interests of a recruit’s spouse or partner (including job opportunities), pay for as much of the site visit as possible, and follow-up after the visit.30 A survey of recent female recruits in the Pacific Northwest identified 3 important focus areas for positive rural recruitment experiences: cultivating good recruitment relationships, offering attractive practice arrangements, and emphasizing the strength of the medical community.4 Communities are more likely to recruit female physicians if they communicate effectively and address spouse/partner, childcare, and scheduling issues during the recruitment process.31 An organized community effort can result in successful recruitment of physicians. A study of South Carolina physicians found that more than half of those who locate in rural communities were actively recruited to establish their practice there, as opposed to only 31% of those in urban communities.32 Combining traditional recruitment activities with community development allowed the Arkansas Southern Rural Access Program to recruit 8 new primary care providers to an underserved rural area in a 2-year period.33 The recruiter worked with local providers, community leaders, and residents to design and implement various improvements that would make their rural community more attractive to new health care providers. Development of a “regional recruiter” position that involved community members in recruitment and retention of primary care providers proved to be cost effective and was replicated in several other Southern states.

Experiences During Residency. Family practice residency programs that graduate higher numbers of rural physicians share similar qualities, according to Bowman.24 These programs had more required rural and obstetrical training months, were located in rural states, and had a full or partial rural mission. Unfortunately, these programs also had fewer residents who were minorities or females, 2 groups that are of importance to the rural health workforce. The University of New Mexico (UNM) family medicine residency program has more rural-background and minority residents choosing rural practice than all other UNM specialty graduates combined (25.9% compared to 10%). Three residency sites for several rotations were created outside the Albuquerque metropolitan area. Residents also participate in a state-sponsored locum tenens program providing practice relief for rural practitioners. A greater percentage of ethnic minority graduates from UNM practiced in rural areas and stayed in the state (44.7%) compared to ethnic minority graduates who were from other medical schools (22.2%).25 Spending large amounts of time in rural areas during residency reinforces practitioners’ affinity for those areas. Rural training tracks (RTTs) are “one-two” programs that require residents to spend 1 year in an urban-based residency and 2 years in a rural community. RTTs have a high number of graduates who remain in rural areas to practice. Rosenthal26 studied 13 RTT programs that collectively produced 67% of graduates with a primary office ZIP code in a rural community, and 61% that practiced in a designated Health Professional Shortage Area (HPSA). Some studies show that rural practice selection is lower among women.4,5,11 However, Rosenfeld and Zaborlik conducted a survey of family practice residency graduates in southern Appalachia that found that more women than men were practicing in small towns.27 Characteristics of the physicians’ practices were similar, as were their reported reasons for choosing a practice location.

Retention. What is the relationship between physicians’ training, the physicians’ self-preparedness for rural life, and retention? Pathman and colleagues collected data to study how prepared physicians felt themselves to be when they began working in their first rural practice for the requirements of medical practice and the “realities of living” there.34 Asked to identify

Recruitment of Physicians. A strong correlation exists between the state or region in which a physician The Journal of Rural Health

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. . . . . Workforce Issues . . . . .

the single experience that had best prepared them for rural practice, 54% responded growing up in a rural area. Physicians also cited having 3 or more clerkships and residency rotations in rural areas as providing them with their best preparation for rural practice. According to Pathman’s survey, physicians who self-reported feeling “more prepared” or “prepared” for rural life were twice as likely as unprepared physicians to still be there 6 years later. According to research conducted by Rabinowitz et al,35 the typical primary care physician remains in rural practice in the same area for approximately 7 years. Increasing rural physicians requires replacing those who leave and then adding additional doctors. According to the authors’ study of long-term (11-16 years) retention of graduates from the first 9 years of the PSAP in Pennsylvania, the PSAP is the only program whose outcomes have been shown to result in multifold increases in both recruitment and long-term retention.35 In light of recent national recommendations to increase medical school enrollment by 15%, Rabinowitz urges that some of this growth be allocated to developing and funding programs similar to the PSAP as an effective way to address the rural physician shortage.35,36 Loan forgiveness or return-of-service (ROS) agreements have long been used as a tool for recruitment of rural physicians. Do these agreements result in long-term retention as well? Sempowski reviewed the literature on ROS agreements and found 10 articles on this topic that were judged to have the highest levels of evidence.37 The author’s review concluded that while most studies showed effective recruitment, the one prospective cohort study revealed that physicians who voluntarily chose to go to a rural area are far more likely to stay in the long term than are those who locate there as a result of an ROS commitment.

for most schools and residency programs. As long as the largest funding streams available to academic health centers are based on research productivity, then the primary agenda will remain as research excellence as defined by procurement of grant and research dollars. The historic 3-part mission of most academic health centers (education, clinical care, and research) does not speak to the more specific need to graduate physicians who will choose to practice in rural communities. To succeed, these programs must be funded in a way that implements proven strategies and rewards meaningful results. Simultaneous with the expansion of the medical school pipeline resulting from nationwide class size increases, there is increased attention focused on developing new and expanding existing residency programs. These expansions offer a unique opportunity to attempt new programming to address physician distribution challenges. To encourage innovative changes in medical education that include attention to physician distribution issues, a funding priority or a funding expectation must be articulated to encourage medical schools and residency programs to think creatively. The move toward outcome measures as a condition of state funding is a potential opportunity to leverage programs that prioritize geographic graduate distribution goals. Providing financial incentives to programs that produce graduates at a defined level who choose practice in a rural area would encourage medical school faculty buy-in and creativity in addressing this challenge. A far more subtle change must also occur. Currently, the leadership in academic medicine speaks about distribution and shortage challenges, but most commonly continue to provide larger resources and priority access to specialty and sub-specialty departments and faculty largely due to the higher clinical revenues generated by these units. Further, the constant pressure to obtain outside funding from federal and private grantors is a disadvantage for primary care-oriented departments, for whom access to such funds is limited. Yet, these departments produce the physicians most likely to practice in rural areas. Individual faculty prestige, promotion, and monetary rewards are largely tied to the ability to procure funds through research or clinical revenue rather than the ability to mentor students into needed disciplines, implement community-oriented curricula, and shepherd students and residents toward practice in HPSAs and/or rural areas. Present recruitment resources that encourage graduates to seek a practice in a rural community are minimal or nonexistent at most institutions.

Policy Issues The search to find effective solutions to the problem of physician geographic distribution is not new, as evidenced by the wealth of published research. The need to define “what works” is not the pressing issue; rather, the needs are to define the commitments necessary to implement proven strategies and strengthen the will to change the status quo. Academic health centers are pressured to perform on many stages, including providing care for the indigent, educating highly trained practitioners, and producing voluminous research findings to add to the body of knowledge influencing clinical practice. Graduate practice location choice is, at best, a minor agenda item Ballance, Kornegay and Evans

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Conclusion

4. Ellsbury KE, Baldwin LM, Johnson KE, Runyan SJ, Hart LG. Gender-related factors in the recruitment of physicians to the rural Northwest. J Am Board Fam Pract. 2002;15(5):391-400. 5. Kassebaum DG, Szenas PL. Rural sources of medical students, and graduates’ choice of rural practice. Acad Med. 1993;68(3):232-236. 6. Whitcomb ME. The challenge of providing doctors for rural America [comment]. Acad Med. 2005;80(8):715-716. 7. Hauer KE, Durning SN, Kernan WJ. Factors associated with medical students’ career choices regarding internal medicine. JAMA. 2008;300(10):1154-1164. 8. Easterbrook M, Godwin M, Wilson R, et al. Rural background and clinical rural rotations during medical training: effect on practice location. CMAJ. 1999;160(8):1159-1163. 9. Laven G, Wilkinson D. Rural doctors and rural backgrounds: how strong is the evidence? A systematic review. Aust J Rural Health. 2003;11(6):277-284. 10. Woloschuk W, Tarrant M. Do students from rural backgrounds engage in rural family practice more than their urban-raised peers? Med Educ. 2004;38(3):259-261. 11. Tolhurst HM, Adams J, Stewart SM. An exploration of when urban background medical students become interested in rural practice. Rural Remote Health. 2006;6(1):452. 12. Colwill JM. Education for and retention in rural practice. J Rural Health. 2003;19(3):233-235. 13. Rabinowitz HK, Diamond JJ, Markham FW, Hazelwood CE. A program to increase the number of family physicians in rural and underserved areas: impact after 22 years. JAMA. 1999;281(3):255-260. 14. Blue AV, Chessman AW, Geesey ME, Garr DR, Kern DH, White AW. Medical students’ perceptions of rural practice following a rural clerkship. Fam Med. 2004;36(5):336-340. 15. Brooks RG, Walsh M, Mardon RE, Lewis M, Clawson A. The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature. Acad Med. 2002;77(8):790-798. 16. Fryer GE, Stine C, Krugman RD, Miyoshi TJ. Geographic benefit from decentralized medical education: student and preceptor practice patterns. J Rural Health. 1994;10(3):193-198. 17. Lang F, Ferguson KP, Bennard B, Zahorik P, Sliger C. The Appalachian preceptorship: over two decades of an integrated clinical-classroom experience of rural medicine and Appalachian culture. Acad Med. 2005;80(8):717-723. 18. Phillips TJ, Rosenblatt RA, Schaad DC, Cullen TJ. The long-term effect of an innovative family physician curricular pathway on the specialty and location of graduates of the University of Washington. Acad Med. 1999;74(3):285-288. 19. Rabinowitz HK. A program to recruit and educate medical students to practice family medicine in underserved areas. JAMA. 1983;249(8):1038-1041. 20. Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA. 2001;286(9):1041-1048. 21. Rabinowitz HK, Diamond JJ, Markham FW, Wortman JR. Medical school programs to increase the rural physician supply: a systematic review and projected impact of widespread replication. Acad Med. 2008;83(3):235-243. 22. Longo DR, Gorman RJ, Ge B. Rural medical school applicants: do their academic credentials and admission decisions differ from those of nonrural applicants? J Rural Health. 2005;21(4):346350. 23. Smucny J, Beatty P, Grant W, Dennison T, Wolff LT. An evaluation of the rural medical education program of the State

In this article, we identified strategies that effectively influence practice location choice toward rural areas. While “nature” or rural background is a common factor in many physicians who choose rural practices, “nurture” or programs that encourage and maintain rural affinity and intent to choose family medicine or primary care are also a necessary component in a budding rural physician’s education and residency. High school programs are shown to encourage rural students to develop an interest in medicine and gain admission to competitive colleges. Undergraduate programs also connect premedical students to local rural practices. Medical school clerkships in rural areas keep students connected to rural life and strengthen their intention to practice in rural areas. Effective recruitment efforts that highlight the positive aspects of rural life and address work-life balance are also shown to attract providers and retain them in their rural practices. These findings are not surprising. The challenge appears to be in generating the will to fund and implement proven interventions widely and with consistency, and in creating a sense of priority around guiding graduate practice location choice. Until the need to provide physicians for all communities is clearly embraced by medical schools and programs are funded and implemented widely, only a limited number of schools will continue to specifically address the needs of rural populations. Given that all medical education is subsidized at some level by state and federal taxes, it would seem fair that all citizens should have some expectation of a return on this investment. Were this indeed the case, all medical schools and residency programs would have some concentrated programming in place to influence practice location and discipline-specific choices. Until these needs are accepted as a mandate to be addressed by all engaged in the medical education pipeline, we will continue to see expansions without specific specialty and geographic targets based on the needs of the states and the nation.

References 1. Office of Rural Health Policy. Facts About...Rural Physicians. Available at: http://www.shepscenter.unc.edu/research_ programs/rural_program/phy.html. Accessed March 2008. 2. American Association of Medical Colleges. 2007 State Physician Workforce Data Book. AAMC: Washington, DC; 2007. 3. Georgia Board for Physician Workforce. Fact Sheet on Georgia’s Medical Schools. 2008. Available at: http://gbpw.georgia.gov/ vgn/images/portal/cit_1210/13/29/111117337Fact%20Sheet% 20-%20Medical%20Education%202008.pdf. Accessed September 2008.

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