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HMS Clinical department review report guide

HMS Clinical Dept Review Program guide.pdf (255.72 KB)

HMS Clinical Department Review Program REPORT GUIDE AND SUGGESTED OUTLINE

Please note that all of the information below, when relevant, should be captured by the report. Department Heads may choose to organize the presentation of some of the data under subheadings in a way that is more logical for their department. When possible, the following information should be presented in tables or figures. Survey data relevant to the department that has been collected for ACGME accreditation and for institutional assessment of faculty and patient engagement should be both summarized in the report and also included in the appendices.

Department Chair’s Narrative

  • Executive summary
  • Department at a glance
    • Leadership and organizational chart
    • Divisions, programs, and services
    • Sites and locations of clinical care delivery, training, and research
    • Residency and fellowship programs
    • Numbers of faculty, residents, and fellows
    • Numbers of non-faculty MD providers, APPs, and staff
  • High level summary across research, educational, and clinical domains
    • Notable accomplishments and strengths
    • Areas of opportunity and focus
    • Areas of concern and for improvement
    • Barriers to success and anticipated challenges
  • List key recommendations from the most recent review and describe relevant outcomes (if appropriate/applicable)

  • Goals, plans, and strategic opportunities over the next five years

Clinical Activities

  • Executive summary
  • Clinical services organization
    • Divisions, programs, and other units
    • Sites of clinical care delivery
      • Indicate which sites host students & trainees
      • Indicate level and type of services provided
  • Breadth and volume: Department as a whole and subspeciality units
    • Clinical strengths
    • Clinical FTEs
      • Adequacy of clinical provider staffing and of their support staff
    • Numbers & types of clinical visits and procedures, if relevant
      • Comprehensiveness of services offered
      • Sub-specialty, tertiary, and quaternary care
    • Identified service gaps
    • Growth/regression of services (past 5 years)
    • New programs launched or planned (strategic goals)
  • Quality and safety

    • Describe how quality is measured for providers and services in the department (e.g., patient outcomes, wait times, 360s, regional and national ranking (e.g., USNWR, Press Ganey), Leapfrog safety grades,

      Magnet designation, OPPE/FPPE, JCAHO, etc.) and include a summary of these quality measures

  • How does the department’s clinical performance compare with relevant national benchmarks for patient outcomes?
    • Patient-reported data on access and satisfaction
    • Identified areas for improvement
    • Accreditation status and citations, if any
  • Indicators of clinical excellence and distinction
    • Reputation/recognition/national standing [best in class care]
    • Centers of Excellence
    • Clinical innovation and patents, if relevant
    • Referrals from outside of the region
    • Faculty leadership in national networks, cooperative groups, and specialty societies
  • Alignment of clinical services with hospital initiatives and goals
  • Department’s capacity to meet clinical service needs of other departments and collaborate effectively
  • Financial performance of practices
  • Constraints and resource availability

Research Activities

  • Executive summary
  • Description of research programs
    • Basic science
    • Translational
    • Clinical trials
    • Epidemiologic and outcomes
    • Quality and safety
  • Departmental infrastructure and resources supporting research
    • Personnel to support study design; clinical trials support; statistical analyses; large database storage, access, and interrogation (including genomics, proteomics, etc.); IRB submission; grants management and other research assistance
    • Equipment
    • Bridge and seed funding
    • Conferences and workshops
  • Funding (sources and amounts of awards)
  • Extramural funding
    • NIH and other federal research grants and contracts
    • NIH Training Grants
    • Industry-Sponsored research
      • Investigator initiated
      • Sponsor initiated
    • Foundation funding
    • Philanthropic research support
    • Other
  • Intramural funding
  • Departmental
  • Institutional
  • Harvard Medical School
  • Trends in peer reviewed and total support over the past 5 year period (e.g., comparison to peers based on Blue Ridge Institute for Medical Research Rankings data).
  • Novel research programs
  • Key publications (optional)

Educational Activities

  • Executive summary
  • Medical student teaching
    • List of faculty contributions to HMS pre-clinical and other courses and HMS student mentorship
    • List of core and elective clinical clerkships hosted; number of HMS students taught/year; sites where HMS students are taught; numbers and institutions of non-HMS medical students taught, if any
    • Course and Clerkship Learning Outcomes and Student Feedback
    • HMS will provide Learning Environment survey data for departments hosting HMS students for core clinical clerkships
  • Graduate student teaching
  • List of didactic courses taught
  • Faculty participation as primary advisor or on DAC
  • Labs hosting MMSc and PhD students
  • Number of graduate students hosted from Harvard and from outside of Harvard, if any
  • Residency and clinical fellowship programs
  • Residency program(s)
    • ACGME credentialed residency program(s, tracks, and number of trainees/year, for which department is the primary or sole site
    • ACGME program residents hosted by department for rotations as a secondary site for a core or elective rotation (primary and other secondary institutions hosting residents; number of trainees/year; indicate number of non-HMS trainees, if any)
    • Residency match performance
    • Current status of graduates (past 5 years)
    • List of training sites
    • Educational conferences and research opportunities and protected time for residents
    • Director and core faculty
    • ACGME correspondence, program status, and surveys from past 5 years
  • Fellowships
    • Specialty areas, duration of fellowship, and trainees/cohort
    • Hosted by department as the primary or sole site or for rotations as a secondary site for a core or elective rotation
    • List of training sites
    • ACGME accreditation status and trainee feedback
  • Continuing Medical Education
    • Number & kind of courses taught and cadence
    • Faculty involved & number of attendees

Faculty Development and Support

  • Executive summary
  • Faculty engagement and satisfaction
    • Please list institutional and departmental standardized surveys addressing faculty (e.g., Press Ganey, AAMC Standpoint Survey, Maslach Burnout Inventory, etc.) and cadence, summarize key findings and trends, and include in appendix
    • Percentage completion of annual career conferences; summary of faculty satisfaction and statement of how data are tracked and used to support faculty
  • Academic resources for faculty
    • Mentoring programs for early career faculty and trainees
  • Departmental academic conferences (describe attendance data)
    • Career development programming and support
    • Support for protected time; (distinguish allocation related to administrative and clinical service from time for teaching and research); indicate departmental, institutional, and other sources of support for this time
    • Support for professional development outside of the hospital affiliate (e.g., for courses, conference travel, etc.)
  • Academic productivity
    • Number of unique peer-reviewed original research or other scientific publications with departmental faculty or trainee as author or co-author (annually for past 5 years)
    • Number of peer-reviewed research publications with first, second, second to last, and/or last authorship (annually for past 5 years)
    • Faculty development/retention
  • Appointments and promotions
    • Faculty numbers across ranks
    • Promotions (past 5 years)
    • Average time at rank for current faculty
    • Department processes and personnel supporting faculty promotions
  • Faculty recruitment and retention
    • Faculty hires (past 5 years)
      • Via search
      • Via training program
      • Other
    • Faculty departures
      • Retirement
      • Departure for another academic institution (include destination and whether recruited to a leadership position)
      • Other
  • Workforce adequacy and plans for expansion or reduction
    • Specific hires planned
    • Anticipated retirements or departures
    • MD equivalent health providers without faculty appointments

Leadership/Administration

  • Leadership
    • Organizational chart with leadership for programs, divisions, and sites if applicable
    • Leadership opportunities for talent retention
    • Leadership development training
  • Governance
    • Committees (include membership & selection)
    • Process for decision making and soliciting perspectives
  • Communication with department faculty, trainees, and staff
  • Community-building (meetings, town halls, retreats, etc.)
  • Departmental culture and milieu

Department Finances: annual and five-year total – showing historical trend

  • Income: stratified and aggregate
    • Clinical Income (gross and net)
    • Research Support (direct and indirect)
    • Hospital Support
    • HMS Support
    • Endowment Income
    • Philanthropic support
    • Income from royalties, IP, and investments
  • Expenses: Total
    • Salaries & Fringe
    • Aggregate Faculty Salaries – compare to AAMC standards; comparable institutions
    • Incentive Compensation
    • Operating Expenses
    • Research Overhead
    • Capital Expenses

Resources

  • Space
    • Research Space: support/sq. foot
    • Clinical Space
    • Administrative Space
    • For departments with core clerkships, educational space for medical students
    • Description of geographical location of sites and issues relating to co-location and transportation
  • Major Equipment
  • Institutional core resources
  • Level and quality of IT infrastructure
    • Computational and other software resources
    • IT support
  • Administrative and ancillary support
    • Please describe adequacy of staffing, co-location when relevant, recruitment, retention, and vacancy rate (past 5 years) for
      • APPs and other clinical staff support
      • Administrative support
  • Fund-raising/marketing/P-R

Strategic Plan

  • Strategic planning approach and participation
  • Synopsis of existing plan and date of last plan
  • Alignment with hospital and health system strategic plan

Appendices

  • Full faculty list: Format should be Excel spreadsheet (sorted by rank) and should include the following columns: Name, Degree(s), Academic Appointment, Year at Appointment, Years Since First appointment, Full time/Part time, Specialty, Primary Work Site; Secondary Work Site(s), and Apportionment of Time;

    • Current department faculty biosketch or CV

    • Faculty composition slides produced by the HMS Office for Faculty Affairs

PLEASE SUBMIT 2 OR MORE HARD COPIES AS REQUESTED ALONG WITH ELECTRONIC COPY OF REPORT AND APPENDICES 4 WEEKS PRIOR TO REVIEW