Community Response
Panel 2: Quality and Balance in Education
Strategic Planning Leadership Retreat
Chaminade, Santa Cruz, California
January 31 - February 2, 2008
The Stanford School of Medicine Strategic Vision:
Translating Discoveries -- Improving Quality and Fostering Balance
Agenda | Summary | Initiatives
AGENDA
| THURSDAY, JANUARY 31, 2008 | ||
| 1:00 pm | Welcome and Introduction | Philip Pizzo |
| Creating and Sustaining a Culture of Quality | ||
| 1:30 pm | Keynote Speaker: Stanford – Creating a Model University for The Future | John Hennessy |
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| 2:30 pm | The critical impact of public perception on medical quality: Vital lessons from the airline industry. | John Nance |
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| 4:00 pm | Panel #1: Quality and Balance: Applying Lessons From Other Settings to Academic Medicine | Philip Pizzo Clarence Braddock Chris Dawes John Freidenrich John Hennessy John Nance Lucy Shapiro Hannah Valantine |
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| 7:30 pm |  Academic-Industry Relations: Troublesome Aspects |
Jerome P. Kassirer |
| FRIDAY, FEBRUARY 1, 2008 | ||
| Quality and Balance in Education, Training and Research | ||
| 8:00 am | Panel #2: Quality and Balance in Education | Philip Pizzo Tom Clandinin Myriam Curet Gabe Garcia Rob Jackler Mark Krasnow Charles Prober John Pringle |
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| 10:15 | Panel #3: Enhancing Quality and Balance in Research | Philip Pizzo Harry Greenberg Ralph Horwitz Karla Kirkegaard Daria Mochly-Rosen Roel Nusse David Stevenson |
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| 1:30 pm | Worlds in Collision: Time for a New Business Model for Biomedical Research? |
David Korn |
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| 2:30 pm | Panel #4: Fostering the Highest Quality Patient Care | Philip Pizzo Mariann Byerwalter Alan Garber Henry Lowe Martha Marsh Norm Rizk Christy Sandborg Paul Sharek Kevin Tabb |
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| 7:30 pm | A Conversation With Andy Rosenthal | Paul Costello Andy Rosenthal |
| SATURDAY, FEBRUARY 3, 2007 | ||
| Developing Quality and Balance as a University | ||
| 8:00 am | Panel #5: Aligning the School of Medicine with the University and The Stanford Challenge | Philip Pizzo |
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Ann Arvin Michael Longaker |
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Gary Schoolnik Buzz Thompson |
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Coit Blacker Lucy Tompkins |
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| 11:30 am | Wrap-up and Farewell | Philip Pizzo |
SUMMARY
At this year's Strategic Planning Leadership Retreat, which took place January 31st -February 2nd, we addressed the theme of "quality and balance" in relation to our missions in education, research and patient care. This was the seventh annual Leadership Retreat I have led since coming to Stanford in April 2001. As with past events, we assembled nearly 100 faculty, students, and staff from across the Medical School, Hospitals, and University to participate in dialogue and discussion to help guide the future of the Medical School and Medical Center. The character and goals of each Retreat have varied. Some have provided reports and updates on past strategic planning efforts. Others have focused on new initiatives such as diversity and leadership. In the 2008 Retreat I felt we needed to think through some of the difficult challenges that lie ahead as we attempt to improve our quality and maintain the balance within and among our missions in a period of constraint – whether in funding, land use, faculty size, perceptions or expectations.
I chose the dual themes of quality and balance because they both compel us to establish priorities and choices. We all want to have the highest quality programs in education and research and we certainly want to deliver the highest possible quality in patient care. But how do we achieve and sustain that quality within the scope of resources? And how will the priorities we set impact our future directions?
As I have often pointed out, in comparison to many of our peers we are a small school of medicine. To sustain our uniqueness and excellence we have been building on our history and the work of those who came before us. We consider Stanford to be a research-intensive school of medicine, and we define our focus of excellence accordingly. We have to assure the quality and balance of our research efforts, which range from basic discovery to translational and clinical research. Tilting too much in one or another direction would change the character of our school, including its faculty and students, and could change us irrevocably. This is all the more so when our size is limited – whether by faculty billets, class size, facilities or resources.
From my perspective the best way to prepare for the future is to plan for it and help guide it. This means asking difficult questions and then seeking solutions to what may be complex or apparently unsolvable problems. For example, we all know that the funding climate for research has changed significantly during the past several years and that the functionality of the healthcare system in the US is severely compromised. We cannot count on a change in government leadership to overcome the serious fiscal challenges facing our nation or the fact that the current economic downturn will likely impact the support we might have anticipated from philanthropy and foundations. At the same time we must recognize that we are fortunate to be at an institution like Stanford, which has resources –in human, intellectual and monetary capital –that if appropriately guided might lead to new models to preserve and even enhance our success now and into the future.
It is all too easy to assume an attitude of doom and gloom when economic or related events loom on the horizon – and it is certainly true that if we give in to those fears, they will become a self-fulfilling prophecy that will in fact be realized. And while one can't be Pollyannaish and live in denial, it is also true that we can make progress if we exercise creativity and optimism. It is also true that our ability to move forward is enhanced when there is a clear and transparent understanding of our individual and shared goals – which is certainly a major dividend of a retreat that brings the different members and constituencies comprising our medical center and university community into a common dialogue.
To promote dialogue, we conducted three panel discussions, each designed to elicit comments from attendees as well as the panel participants. In each case we received a number of thoughtful comments and suggestions. These will be formulated into action items that we will address in coming months.
Optimizing Quality And Balance In Education
- How do we balance the goal of training leaders and future physician-scientists/scholars and bioscience students with balancing the diversity of interests and individuals we admit to Stanford? What is the right balance of students planning for careers in academia, industry, clinical practice and others?
- How do we measure the quality of our education programs for MD students? More specifically, what methods should we use to evaluate student performance in addition to the courses, clinical rotations, mentoring and other education programs we offer? And how do assess whether the career paths our students are choosing are consonant with the goals we have set for our medical student education program?
- How do we maximize and measure the quality of our educational programs for Ph.D. students? How can we provide incentives for faculty to invest effort in teaching? What kind(s) of monitoring and feedback will ensure that our courses cover the proper material, do it effectively, and serve both their core constituencies and students from other programs who need knowledge in that area? How do we assure that our curriculum and offerings are as valuable as we can make them?
- How do we achieve breadth of training and interdisciplinary skills without sacrificing depth and mastery of one or more disciplines and without requiring an excessive duration of training? Are we really providing students with a broad choice of interdepartmental opportunities or, when all is said and done, are we restraining them to departmental affiliations? Can we do anything else to allow young scientists to achieve independence at an earlier age? Do we need new kinds of educational models or academic positions to achieve these ends?
- How do we find the right balance in the quality of residents and other trainees coming to Stanford training programs to secure both outstanding clinical work - but also a stronger focus on professional development? How can these be balanced given the time limits now in place? How do we create a more medical center wide initiative for professional development and research opportunities for residents and clinical fellows that transcend the departmental boundaries that currently exist? How do we make our residents and clinical fellows become medical school and university citizens in addition to hospital and departmental employees?
- Continuing Medical Education (CME) has largely followed a model of medical lectures and updates which are increasingly demonstrated to have little impact on the quality or outcomes of medical practice. How can we leap beyond the traditional models that exist at most academic medical centers and take a lead in transforming our continuing professional education programs so that they achieve the breadth and quality typical of other School of Medicine educational programs? How can we better utilize the resources that are now available on campus – and that will be abundantly so when the Learning and Knowledge Center opens in 2010 – to create a new paradigm for CME?
Enhancing Quality and Balance in Research
- Recognizing that the quality and excellence in basic science is what distinguishes Stanford, how do we assure it remains outstanding in the future?
- There is a feeling among a number of basic science faculty that they are being ignored in the current medical center and university environment. How should we address this? What do we need to do to assure that we have the best balance among our priorities and also the highest overall quality of our faculty for basic as well as translational and clinical research programs?
- As we select faculty, how do we assure that we are really getting the highest quality individuals - in basic science and in clinical medicine? How do we balance programmatic needs with individual excellence?
- How important is it to our research effort to solve the problem of inadequate and overcrowded research animal facilities and where does it fit in our assignment of research priorities?
- What practical steps can we take to make sure that the goals of the hospitals and the school are more closely aligned in terms of allocating resources to the research mission of the medical center in translational and patient-oriented research?
- As we approach the faculty billet cap, how will we choose among multiple departmental needs when each billet becomes available? What role can non-faculty positions play in meeting needs for which there are no available faculty billets?
- What are the cultural parameters of a zero-sum game? How can we create a culture that acknowledges quality through measures other than accumulated resources – especially at a time when there may be constraints on resources or increased competition for them?
Fostering the Highest Quality Patient Care
- The metrics currently used to measure clinical quality need to address clinical practice outcomes in a manner that allows comparisons across the nation. They must also have "local credibility" in order to drive clinical care processes. What are the similarities and differences that apply to: medical vs. surgical; adult vs. pediatrics; community vs. academic; innovation and clinical research vs. standardization and evidence-based medicine?
- What is the role of Informatics in fostering the highest quality patient care? How might Stanford leverage Clinical Informatics to improve the safety and quality of patient care?
- Do instruments for assessing clinical excellence need to be particularly good at identifying low-quality physicians or identifying high-quality physicians? Or should our efforts be dedicated to finding instruments that will distinguish clinical quality throughout the entire spectrum?
- How can we measure the clinical quality of individual providers, particularly when much care is dependent upon the work of teams? And how can we handle quality measurement for low-volume providers, such as UTL faculty who may devote 25% or less time to patient care activities, and across a wide spectrum of health conditions?
- How heavily should clinical performance be weighted in the different faculty lines - UTL, MCL, and Clinician Educator? What are the best incentives to put into place to promote superior clinical performance throughout SHC?
- How do we change the culture at Stanford so that it is focused on quality at all levels and dimensions? Given our faculty caps and clinical responsibilities, how do we ensure career development for each faculty line?
- How can we leverage quality and safety in our highly innovative and tertiary/quaternary care environments to enhance our institutional profile (e.g., payer contracting, public transparency, reputation, research)?
- How should we select the highest quality projects and opportunities to present to our donor community? How do we strike a balance between the multiple meritorious needs and expectations - especially between our primary missions in research, education and patient care?
In addition to the discussions noted above we also had two other themes for the Retreat. One was to seek lessons from other industries that might inform how we approach the challenge of sustaining quality and balance in an academic medical center. We had an interesting discussion about the lessons from the airline industry delivered by John Nance, noted author and airline pilot, who has written and spoken extensively about this topic. We also heard about lessons from the Pharmaceutical/Biotech industry, IT, Venture Capital and Hospital industries. These were further framed with discussions about instilling these lessons into our ongoing important initiatives in professionalism, leadership and diversity.
Second, we had the opportunity to reflect on the current and future role and goals of Stanford University from a keynote speech by John Hennessy, President of Stanford University that opened the Retreat. To bookend that broad perspective, our final session considered how the medical school and center relate to the major initiatives that are part of the Stanford Challenge: the Initiative on Human Health, the Initiative on Energy and the Environment and the International Initiative. Each evoked spirited and interesting discussions and further framed the exciting prospects for interdisciplinary education, research and service that is unfolding at Stanford.
In addition to sharing facts and figures, thoughts and perspectives, conceptions and misconceptions, one of the most valuable aspects of these retreats has been the community building that takes place among the participants. Whether one has attended all seven Retreats or whether this was the first, I feel confident that each attendee learned something about the medical school, medical center and university that she or he had been unaware of. Hopefully these insights also revealed the highly individualized as well as the broader institutional issues and challenges we face. And while I am confident that individuals reacted to the presentations and discussions through their own personal lenses, it is my hope that our community is more aligned – and more willing and able to work collaboratively to solve some of the challenges facing us in the months and years ahead.
– Philip A. Pizzo, M.D.
Dean, Stanford University School of Medicine
(Source: The Dean’s Newsletter, February 11, 2008.)
INITIATIVES
Based on the comments received from the School of Medicine community and the distillation and analysis of the discussions that took place at the Retreat, I now want to share with you some of the initiatives I will be bringing forth during the next year. It is important to note that these are not all of our high priority initiatives, but rather those that relate to the Retreat theme of achieving excellence while being attentive to sustaining quality and balance among our missions in education, research and patient care. There are several overarching issues as well as ones that are mission-specific.
Some Overarching Issues
- One of the most important overarching issues we will be addressing on "quality and balance" over the next year will be reconciling our plans for growth (especially in clinical care initiatives) with the size and scope of our faculty and the potential limitations that may be imposed if the current billet cap remains fixed. For reference, our faculty billet cap is set at 900 and we are now at just over 800 full-time faculty. This effort will be led by Dr. David Stevenson, Vice Dean and Senior Associate Dean for Academic Affairs, and David O'Brien, Director of Institutional Planning.
- Given the likelihood of continued constraints on research funding from the NIH and other federal sources, we need to develop new models for supporting and funding research in an era when federal funding is flat or declining. Included in this area is the need to better define financial support for graduate students and a different model for the use of endowed professorships. To do this I will appoint a task force led by Marcia Cohen, Senior Associate Dean for Finance and Administration.
- Because of the limitations of our size, resource restraints and the tensions that emerge from having missions in basic and clinical research as well as education and patient care, there is a continuing need to find ways to make all members of our community -- students, staff and faculty -- feel both engaged and valued. This is something we all need to be part of and I will personally seek ways to help assure that we each share in securing the "quality and balance" of our community.
- There is a need to continue to address academic and staff leadership succession planning, including an assessment of the impact of transitions of faculty and staff on resource consumption and strategic initiatives. The Dean's Office will take the initiative in working on this issue.
- One of the greatest and most distinctive strengths of Stanford is the opportunity for interdisciplinary research and education. With the Stanford Challenge now underway (a topic we spent time discussing at the 2008 Leadership Retreat), it is clear that we need to find better ways to engage faculty and students in the Initiatives on Energy and the Environment as well as the International Initiative and the Initiative on Human Health. The responsibility for this will lie with basic and clinical science chairs, Institute Directors and, of course, faculty and students. We will seek ways of making the opportunities that are available more broadly known and accessible to our community.
Quality and Balance in Education
Medical Student Education
- We need to address ways to assure diversity in our medical student body within the context of our New Curriculum and our focus on training and developing physician scholars, scientists and leaders. This will require addressing the alignment between our institutional goals, the criteria of our admissions committee and the expectations and goals of prospective and admitted students. In tandem with assuring diversity in our entering classes, we will also recommend ways to assure the success of minority students while at Stanford. I will appoint a Task Force led by Dr. Charles Prober, Senior Associate Dean for Medical Student Education, to address this issue.
- An observation and concern that emerges from various surveys and reviews is that we do not, as an institution, place sufficient value in clinical education (and, to a degree, in education overall) and the roles played by faculty in patient care activities in comparison with some of our peers. In tandem with this is the need to better determine the metrics by which to evaluate the clinical performance of medical students in a manner that is data driven and transparent. This is especially important as we seek to better define the tools used to evaluate student performance more broadly, including the official school letter (or "Dean's Letter"). A review of these important issues will be led by Dr. Charles Prober, Senior Associate Dean for Medical Education, in collaboration with Drs. Hannah Valantine, Senior Associate Dean for Diversity and Leadership, and Gabe Garcia, Associate Dean for Medical Student Admissions.
PhD Education
- To improve the quality of graduate student education, we will initiate a peer review of current graduate courses by students and faculty. The questions to address include whether we are really educating students for the jobs they will eventually hold and whether there is enough breadth of topics, including ones that extend to business and law and that provide a wider breath of experience including "PhD Internships." We also need to assess whether our graduate education programs are truly achieving the interdepartmental/interdisciplinary focus we espouse or whether they are really still more departmentally focused. This review will be led by Dr. John Pringle, Senior Associate Dean for Graduate Education and Postdoctoral Affairs, and Dr. Ellen Porzig, Associate Dean for Graduate Education.
- Without question, postdoctoral scholars and clinical fellows are among the most important members of our academic medical community but also among the most disenfranchised. We need to develop improved ways of integrating postdoctoral scholars into the broader missions and opportunities of Stanford and to assure mentoring and transitional appointments that better prepare them for faculty or other careers. These issues will be addressed by Dr. John Pringle, Senior Associate Dean for Graduate Education and Postdoctoral Affairs, and Chequeta Allen, Assistant Dean for Postdoctoral Affairs.
Graduate Medical Education (GME) and Continuing Medical Education (CME)
- We need to develop recommendations for programs that measurably improve the quality and diversity of GME programs. This effort will be led by Dr. Myriam Curet, Senior Associate Dean for Graduate Medical Education.
- We need to develop a fundamentally new approach to CME based on improving quality metrics of clinical performance and on more individualized education compared to traditional lecture formats. I plan to appoint a Task Force led by Dr. Rob Jackler, Associate Dean for CME, to develop new and novel approaches that can make Stanford a leader in CME.
Enhancing Quality and Balance in Research
- In addition to developing new financial models to support our missions in research during an era of constraint (see above) we also need to develop new models to support our research mission within Stanford, including how we use cores and shared services. This includes where they are located, how they are managed and funded, and how they can sustain a balance between service and innovation. This effort will be led by Dr. Daria Mochly-Rosen, Senior Associate Dean for Research.
- We have reached a critical phase in our planning for laboratory animal programs -- including space (both onsite and offsite), financing and a better delineation of which models should be employed. Given the transition of leadership in Comparative Medicine that will occur in the next year, these and related issues are timely and important. They impact the School of Medicine as well as the rest of the University. Accordingly, a review group will be led by Dr. Harry Greenberg, Senior Associate Dean for Research, and Dr. Ann Arvin, Vice Provost and Dean of Research.
- Although we have made "Making and Translating Discoveries" our overarching institutional priorities, we have work to do in better defining how the Medical Center can achieve success in clinical and translational research as well as research that results in improved quality of patient care during a time of resource constraint. In considering this issue we need to better delineate how hospital based clinical research is supported and funded and who will carry it out. A review of these issues will be assigned to Dr. Ken Cox, Senior Associate Dean for Pediatrics and Obstetrics Clinical Affairs, and Dr. Norm Rizk, Senior Associate Dean for Clinical Affairs.
- It has been observed that members of the Stanford community are often unaware of the research breakthroughs being made by their faculty and student colleagues. We need to develop better ways to communicate research discoveries and successes to our Stanford community. This review will be led by Paul Costello, Executive Director of Communications and Public Affairs.
Fostering the Highest Quality Patient Care
- During the past year several programs have been initiated to address quality performance at SHC and LPCH, and a Center for Quality and Efficiency is to be established. Because of this, we will not recommend new initiatives per se. That said, we need to continue to support these initiatives and also assess ways of better linking them to efforts underway by our colleagues at the Palo Alto VA Medical Center. In conjunction with these efforts, we also need to better define the important role that our Clinician Educator colleagues play in enhancing our missions in education, clinical research and patient care. Importantly, we need to delineate ways to make the role of Clinician Educators more valued and appreciated. This review will be led by Dr. David Stevenson, Vice-Dean and Senior Associate Dean for Academic Affairs.
It is important to note that these initiatives are a subset of those that we will be working on during the next year. There are other major tasks we face -- especially in the development and support for medical center facilities. But the outline above conveys the ways we will follow up on some of the important suggestions emerging from the 2008 Strategic Leadership Retreat.
– Philip A. Pizzo, M.D.
Dean, Stanford University School of Medicine
(Source: The Dean’s Newsletter, February 25, 2008.)