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Completed Projects
Transforming Academic Medical Centers
Carol VanDeusen Lukas, EdD
Lois Camberg, PhD
Charu Taneja, MPH
OBJECTIVES: Since the publication of the Institute of Medicine's report, Crossing the Quality Chasm, in 2001, many medical centers have increased their efforts to improve the quality of care they provide while at the same time increasing their efficiency; some are striving to fully transform their systems. Academic medical centers, however, seem to face particular challenges in substantially changing their systems to improve performance. The objective of this study was to analyze and describe the factors that affect organizational change in academic medical centers, focusing especially on the role of the medical school affiliates and on the impact of change on the academic mission of the medical centers. The organizational change examined was the creation of three health care systems in the Department of Veterans Affairs (Chicago, New York Harbor and Boston), each formed by the integration of two medical centers with strong affiliations with different medical schools.
STUDY DESIGN: In this multiple-site case study, the three systems were analyzed over two years. Data were drawn from three sources: 1) Interviews: Semi-structured interviews were conducted with key VA medical center and medical school leadership, and with selected clinicians, residents and researchers at three points in time. The interviews gathered information about a) the structure of the integrated system, b) the integration processes, c) the role of the affiliates, and d) the effects of integration on teaching programs and research. 2) Employee surveys: Surveys were administered in Boston and New York Harbor to obtain employee reports about their experiences in the integrating systems; response rates ranged from 47% to 53%. 3) Administrative databases: Facility-level data on system performance and characteristics were drawn from VHA administrative databases and records.
FINDINGS/RESULTS: The three systems used three approaches to clinical integration: a) wait and see, b) targeted opportunities, and c) full consolidation. The extent of clinical integration was directly related to the strength of support or opposition of the medical schools. The impact of integration on the academic mission of the systems was strongest in the full-consolidation system. The challenges faced in this system provide lessons about organizational change in four areas: a) transition issues; b) implementation challenges; c) organizational structure challenges; d) response to external pressures. The systems with more clinical integration showed stronger efficiency improvement between FY98 and FY01, as measured by adjusted costs per workload and adjusted FTEE/1000 workload.
CONCLUSION: The three study systems used similar approaches to integrating administrative services, but followed different approaches to integrating clinical care. The impact on the system was greater when more changes were made in the organizational structure. In all three systems, the role of the primary medical school affiliates was key in setting the tone and direction of the integration.
IMPACT: The study has broad applicability in understanding the role of academic affiliates in organizational change, and in offering lessons about the challenges and processes of change in highly-affiliated medical centers.
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