Report of Committee One Institutional Setting Governance and Administration

University of South Florida College of Medicine LCME Institutional Self-Study Report of Committee One: Institutional Setting: Governance and Administration Study Year 2005-2006 Academic Year 2005-2006 Self-Study Report The contents of this report represent the judgments and opinions of the members of this Self-Study Committee The committee has made every effort to ensure that the information represented is accurate The LCME administrators have not audited the data in the text of the report and there may be some discrepancies within the database or executive summary as a result While every attempt has been made to provide and evaluate information accurately and objectively, the committee acknowledges that any errors of fact in this report are unintentional (Printed October, 2006) Table of Contents Committee One Academic Year 2005-2006 Self-Study Report I Executive Summary/Key Issues II III Responses to Questions in Guide to Institutional Self-Study Analysis of Recommendations and Deficiencies Relevant to Committee as Identified by Most Recent LCME Review in 1999 14 IV Major Changes Since Last LCME Review in 1999 14 V.Areas of Strength 14 IV Areas of Concern and Challenges .15 VII Review of Compliance with Established LCME Standards .15 VIII Recommendations, Possible Solutions and Strategies .19 IX Issues of Concern Relevant to Other Committees .19 X Attachments 19 XI Narrative of Process .19 XII Database Accuracy 19 XIII Committee Membership 19 I Executive Summary/Key Issues Committee One Academic Year 2005-2006 II Self-Study Report  The College of Medicine at the University of South Florida has developed an appropriate model of shared governance between the administration and the faculty that facilitates extensive communication and discussion of institutional priorities  The vice president and dean, the vice deans and the clinical and basic science chairs together with the Faculty Council and representative of the student body comprise an effective governance structure that contribute to effective institutional planning with respect to the education, research and service missions of the college  The various administrative and policy committees described in the Faculty Bylaws provide an efficient advisory function to the dean of the College of Medicine  Previous extensive planning and development activities have resulted in the college’s commitment to provide an outstanding educational environment and an innovative curriculum to encourage lifelong learning by medical and graduate students  The implementation of modern information technology has contributed to the success of the college’s educational endeavors  Significant resources have been committed to encourage students to engage in the completion of a number of dual degree programs  While the College of Medicine does not own a “teaching” hospital, cordial relationships have been developed with a number of local clinical institutions that provide appropriate training environments for clinical care delivery These include Tampa General Hospital, the H Lee Moffitt Comprehensive Cancer Center and Research Institute and the James A Haley Veteran’s Hospital  The Board of Trustees and the president of the University of South Florida have adopted an appropriate governance strategy and provide efficient oversight of the operations of the College of Medicine  A number of new facilities, such as the Center for Advanced Healthcare will greatly improve and expand the education, research, and service missions of the College of Medicine Responses to Questions in Guide to Institutional Self-Study Describe how institutional priorities are set Evaluate the success of institutional planning efforts and discuss how planning has contributed to the accomplishment of the school’s academic purpose, research prospects, and goals of the clinical enterprise Committee Response: How are institutional priorities set? While a formal, institution-wide structure provides input and guidance for decisions regarding priorities of the college, final decisions are made jointly by the executive committee of the college; i.e the vice president for USF Health and dean of the College of Medicine as well as the vice deans and the clinical and basic science chairs Included in the structure are the student body and their governing representatives and faculty represented by an elected Faculty Council Reporting to the council are policy committees Committee One Academic Year 2005-2006 Self-Study Report whose authority and responsibility are specified by the Faculty Bylaws of the College of Medicine In addition, there are a number of administrative committees that report to the dean of the College of Medicine The Policy Committees comprise: Committee on Academic Computing Committee on Bylaws Committee on Continuing Medical Education Committee on Curriculum Committee on Graduate Medical Sciences Education and Graduate Student Affairs Committee on Graduate Medical Education Committee on Professional Student Affairs Committee on Research The Administrative Committees comprise: Academic Performance Review Committee Committee on Appointment, Promotion, and Tenure Committee on Medical Student Selection Committee on Space Faculty Relations Advisory Committee Offices of the college administration, as well as the individuals and support personnel, who are assigned to them, complement and assist the major Policy and Administrative Committees These offices include the following: Vice Dean, Educational Affairs …………………………… ….…… Paul M Wallach, MD Vice Dean, Research Affairs ……….……… Abdul Rao, MBBS, MA, DPhil Vice Dean, Clinical Affairs……………….……………………………… Robert J Belsole, MD Senior Executive Associate Dean for Faculty and Academic Affairs … John S Curran, MD Associate Dean for Clinical Practice………………………………… … Enrico Camporesi, MD Associate Dean Quality……………………………………….… … ….…Michael Parsons, MD Associate Dean for Undergraduate Medical Education… .…Bryan Bognar, MD Associate Dean for Academic Enrichment………….………………… Deanna Wathington, MD Associate Dean for Student Affairs and Admissions Steven C Specter, PhD Associate Dean for Research …………………….………………….…….……Lynn Wecker, PhD Associate Dean for Graduate Affairs…………………………….… …Joseph J Krzanowski, PhD Associate Dean for Graduate and Post Doctoral Affairs (Interim)………… Michael Barber, DPhil Associate Dean for Business Affairs and Technology………………… Joann M Strobbe, MEd Associate Dean for Diversity Initiatives………………………….….… Marvin T Williams, PhD Associate Dean for Continuing Professional Development……….… Deborah Sutherland, PhD Assistant Dean for Clinical Outreach……………………………….… Heidi M Stephens, MD Associate Dean for Graduate Medical Education & Veterans Affairs….… … Peter J Fabri, MD Assistant Dean for Student Affairs…………….……….……………… .Carolyn Nicolosi, MS Assistant Dean for Special Projects………………………………….…………Karen M Burdash Executive Director of USF Physicians Group…………………… ….… ….…Joseph M Jackson Director of Admissions…………………………………………… ….……… Robert E Larkin Director of Area Health Education Center……………………….…… Cynthia S Selleck, DSN Director of Business Affairs …………………………………… ……………….….Jean G Nixon Director of Compliance ………………………………………….………………Patricia J Bickel Committee One Academic Year 2005-2006 Self-Study Report This structure provides a mechanism whereby any student or faculty member can introduce ideas and suggestions for change in any area with assurance that they will be formally considered The process for diverse routes of input to the dean is outlined to follow: Figure University of South Florida College of Medicine Routes of Input for Shared Governance Dean of the COM STEPHEN K KLASKO, MD, M.B.A., F.A.C.O.G Executive Council of the COM Department Chairs Clinical and Basic Science Department Faculty Faculty Council of the COM Sandra Gompf, MD President Departmental Delegates and Committees of the Faculty Individual Faculty Members Student Executive Council David Wilson, MS IV., President Class Officers and Representatives Individual Students b) Evaluate the success of institutional planning efforts and discuss how planning has contributed to the accomplishment of the school’s academic purpose, research prospects and goals of the clinical enterprise The pre-eminent mission and responsibility of the college has always been medical student education The 1997 Strategic Implementation plan states “A principle role of the College of Medicine is to select and educate students of Health and Biomedical Science through the creation and support of a scholarly environment of discovery and research The college will foster excellence in the lifelong endeavors of education, research activity, and compassionate patient care relevant to improvement of the health of the community.” The College of Medicine (COM) has engaged in a series of strategic planning activities over the past decade as indicated by the most recent strategic plan There is a high degree of continuity across these planning activities in terms of the over-arching goals of the college: Committee One Academic Year 2005-2006    Self-Study Report A commitment to provide the highest quality and most relevant educational and training programs possible Dedication to conducting basic and translational research that advances knowledge and results in improvements in health and patient care The acquisition, generation and management of financial resources in a manner that makes the realization of these goals possible Evaluation and improvement of the undergraduate medical education curriculum is an on-going process at the College of Medicine Since 1999 the college has made significant modifications in the Year and curricula, moving to a model that is more integrated and interdisciplinary and that places a greater emphasis on the application of important basic science concepts to clinical medicine A critical component of the Year and curricular reforms is the Longitudinal Clinical Experience (LCE) program that pairs first and second year medical students with medical school faculty and private medical practice preceptors for one half-day per week Over the course of two years, each medical student works with three different preceptors in primary and specialty practice areas In early 2004 with extensive faculty and student involvement and aided by the Office of Educational Affairs, the college began “The Program to Advance Clinical Education” (PACE) to evaluate the adequacy of the Years and curricula PACE is being conducted within the context of the numerous published studies that have concluded that the clinical component of U.S undergraduate medical education has not kept up with changes in health care delivery systems, evolving practice requirements, changing patient expectations, increasing emphasis on quality improvement and evidence-based medicine and constant innovations in medical informatics and technology The goals for the new Years and program, which were implemented in 2005-2006, include the following: (a) development of an interdisciplinary clerkship model; (b) creation of a new methodology for oversight of clerkships; (c) assurance that learning experiences expose students to common disorders that are representative of those seen in clinical practice, including important concepts of the major fields of medicine that develop procedural skills appropriate for all medical school graduates, including patients presenting de novo who not yet have a diagnosis; (d) integration of important contemporary issues in medicine; (e) realization of a more robust fourth year; and (f) increase of enhanced technology The new Clinical Skills Center opened in the fall 2005 and is one of the most advanced facilities of its kind in the nation The quality of the USF College of Medicine undergraduate medical education program consistently ranks among the best in the nation, according to national measures such as the following:    USF medical school graduates’ 2001 through 2004 for the first time pass rates on the USMLE Step ranged from 99% to 100% National pass rates ranged from 94% to 96% USF medical school graduates’ 2002 through 2005 for the first time pass rates on the USMLE Step ranged from 99% to 100% National pass rates ranged from 94% to 96% On the AAMC 2004 Medical School Graduate Questionnaire, 51% of USF COM graduates reported that they “strongly agreed” that they were satisfied with the overall quality of their medical education program, as contrasted to 39% of national medical school graduates The college is committed to assuring that our medical school graduates possess the concepts, skills and attitudes required for the effective and successful practice of medicine in today’s healthcare delivery environment In addition to the modifications being made to the Year and Year curricula, several other initiatives are also underway Committee One Academic Year 2005-2006 Self-Study Report The first initiative, internally referred to as the “Physicians Who Get It” initiative, identifies a skill set (including communication and negotiation skills, conflict resolution, leadership and management skills, the ability to work as a team member, etc.) that is considered imperative for today’s practicing physicians to possess The next challenge is to design curricular components for these skills and to reach consensus about how to incorporate them into the curriculum The second initiative underway aims at significantly increasing the number of medical students who graduate with a dual degrees, such as MD/MS, MD/MBA and MD/MPH Highest priority will be given to the MD/PhD in biomedical sciences and a new program in biomedical engineering We also offer MD/MBA and MD/MPH degrees It is the college’s objective that 20% of medical school graduates will ultimately complete a dual degree The college is also actively investigating the creation of a range of “scholarly concentrations” which would permit students to include a focus of study in a specific area of interest during their medical studies Potential “scholarly concentrations” would include community/public health, international health, biomedical ethics/humanities, immunology, clinical research, leadership development, academic medicine, aging, the business of medicine, neurosciences, infectious diseases, oncology, bioinformatics/biostatistics and sports medicine, among others In order for the College of Medicine to achieve the curricular and educational reforms planed for the next five to ten years, it is imperative that the college’s instructional technology resources be significantly enhanced The college has approved and has implemented the following new computer requirements beginning the 2005-2006 academic year:  Notebook computers for all new students will permit each classroom and lab to serve as a computer lab  Handhelds for all third year students will offer students experience with the technologies that now exist in clinical practice Other instructional technology applications being implemented by the college include the following:  An enhanced student clinical encounter system permitting real time review of activities in comparison to benchmarks  Increased use of simulators  Expanded use of computer-delivered testing  Enhanced use of digital imaging for histology, pathology and microbiology Graduate education has been recognized as fundamental to achieving the strategic goals of the College of Medicine These goals include the development and training of future scientists and clinicians who will be responsible for generating pioneering advances in health care and basic research as well as providing the educators and researchers of tomorrow In addition, the development of new, interdisciplinary graduate programs can provide a pool of highly-qualified individuals who can compete for local academic and industrial positions Thus, a strong graduate program that comprises a diverse array of talented Doctoral and Masters students provides an essential complement to the traditional medical student programs and stimulates the research endeavors of the faculty The College of Medicine offers graduate programs leading to the Doctor of Philosophy in Medical Sciences, the Master of Science in Medical Sciences, the Master of Science in Bioinformatics and Computational Biology and the Master of Arts in Bioethics and Humanities The Doctor of Philosophy (PhD) degree in Medical Sciences is available with concentrations in Pathology & Cell Biology, Molecular Medicine, Neuroscience and Molecular Pharmacology and Physiology A combined MD/PhD program is also under development and initial students are being recruited A recent development in preparing students for a research career has been the institution of a Multidisciplinary Biomedical Sciences (MBS) doctoral program that combines strong biomedical Committee One Academic Year 2005-2006 Self-Study Report sciences training with increased research opportunities This program enables students to enter graduate doctoral education in an undifferentiated status by participating in a comprehensive course entitled Foundations of Medical Science Students enrolled in the MBS program participate in a common first semester curriculum that provides an essential background in biochemistry, molecular biology and cell biology, combined with laboratory rotations to identify an area of research and a mentor In addition to the MBS program, students with a specific interest in one department/concentration may apply to both the MBS program and one department/concentration The University of South Florida School of Physical Therapy was established in 1998 within the College of Medicine The first class of 14 students graduated in 2001 and was awarded the entry-level Master of Science in Physical Therapy (MSPT) degree The school has subsequently enrolled 30 students in the MSPT degree program Responding to national educational trends and changes in scope of physical therapy practice within the healthcare environment, School of Physical Therapy faculty developed and submitted a curricular implementation proposal to replace the entry-level MSPT degree with the first professional Doctor of Physical Therapy (DPT) degree Following university review and approval, the Florida Board of Governors granted new degree implementation authority to USF in October 2004, enabling USF to becoming the first public university in Florida to offer the Doctor of Physical Therapy entry-level degree The charter DPT class of 30 students began their 3-year course of study in August 2005 The final two groups of matriculating MSPT students will complete their studies in August 2005 and 2006 A one-year transitional Doctor of Physical Therapy (DPT) degree program is being made available for USF MSPT graduates and will begin in August 2006 Evaluation and improvement of the physical therapy curriculum is an on-going process within the School of Physical Therapy Since August 2004, the school’s curriculum committee has made significant modifications to the new DPT curriculum, building an innovative model that is more integrated and interdisciplinary within the resources of the College of Medicine and Health Sciences Center, and that places our Year DPT students with Year medical students in key “foundations of doctoring” courses These changes were reviewed and approved by the College of Medicine Committee on Curriculum in March 2005 Additional interdisciplinary opportunities are being developed and are evolving outside the classroom, so that teaching and learning together are translated into the teamwork of practicing collaboratively Demand for access to physical therapy education is growing strong The USF School of Physical Therapy has responded to this increasing demand for access to physical therapy education in Florida by increasing its entering class size from 30 in 2004-2005 to 36 (+20% increase) with the implementation of the new DPT degree in 2005-2006 Like many other public schools of medicine, one of the significant challenges facing our program is maintaining and increasing funding for our educational mission in an environment of limited and competitive resources There is the potential for increasing the number of state supported medical schools in Florida which would most likely negatively impact the funding provided to USF COM General revenue funding, as a percentage of the College of Medicine’s operating budget, has declined steadily over the past five years from 22.4% in FY 1999-2000 to 15.1% in FY 2001-2005 This reality combined with increased pressure to produce more clinical revenue and contract grant funding has increased the emphasis placed on clinical practice and research Concomitantly, the college is implementing critical curricular reforms, particularly related to increasing small-group methods of active learning, that are often more costly than the traditional undergraduate medical curriculum Unfortunately, however, some of the educational facilities of the college are 35 years old and inadequate to support further important curriculum reforms aimed at enhancing methodologies and programs within the college While we have recently renovated larger-group classrooms for first- and second-year medical students that are state-ofthe-art, and we have a recently completed innovative clinical skills center, there is still a significant need Committee One Academic Year 2005-2006 Self-Study Report for a building that is designed for small-group instruction, mid-sized programs, learning communities, and simulation Beyond these very urgent needs, a new medical education building would allow the college to achieve greater national prominence and further all of its educational missions Thus with this combination of pressures, the college needs to focus much of its energies on ensuring appropriate faculty and financial resources for the educational mission Evaluate the role of the governance structure in the administrative functioning of the medical school Is the governance structure appropriate for an institution of this size and characteristics? Describe any situations that require review by or approval of the school’s governing board prior to taking action Committee Response: The governance structure of the College of Medicine is well defined in the Bylaws of the Faculty which serve as a “Constitution” for the College of Medicine The dean is the chief academic and administrative officer of the college and is responsible for the implementation of its policies in accordance with university and Board of Trustee’s policies There is a well-defined structure for college organization composed of Basic Science and Clinical Science Departments that reports directly to the dean Each department and the Schools of Physical Therapy and Basic Biomedical Sciences are administered by a director or vice dean who is responsible for the organization and implementation of its programs Recent initiatives have, at times, been less than optimal in assuring bilateral communication and using the faculty structure for initiatives being administratively directed at USF Health Concerns have been recognized and are being addressed quite productively Internal governance is accomplished through two advisory bodies to the dean The first is the Executive Council which is the senior representative body composed of the dean, the department chairpersons, the director of the School of Physical Therapy, and the president and vice-president of the faculty and the president of the College of Medicine Student Government who serves as an ex-officio, non-voting member of the Executive Council This function is now being accomplished by a monthly “All Chairs Meeting” within the intent but not the letter of the Bylaws of the Faculty The College of Medicine Faculty Council is a representative body of the organized faculty which is advisory to the dean and is also responsible for recommendations for both policy and administrative committee nominations It is composed of the Officers of the Faculty, the immediate past-president of the faculty and members of the core faculty elected from each of the departments of the college and the school The Faculty Council routinely meets on a monthly basis to discuss all matters brought before it by any of its members, the dean, standing committees of the college or the executive council Recently it has been used as a “Town Hall” forum to communicate decisions of the administration to the faculty in a “top down” format and not within the intent of the perception of the faculty as a vehicle for shared governance Rapid changes are underway as administratively directed by the USF Health administration which has engendered substantial concern among the faculty relative to the principles of shared governance enunciated in the Bylaws of the Faculty which state the following: “The Faculty Council shall, by majority vote, make recommendations to or advise the dean and executive council on these matters.” Definite constructive efforts have now been made to engage the faculty in a collegial debate over departmental reorganizations, consolidations, and redirection to fulfill the strategic directions enunciated in the Collegiate Strategic Plan as revised in 2006 Collectively, there is optimism that at this time of substantial change there is increased recognition of the importance of engagement of the faculty in the development of new signature programs, reinvigoration and investment in the program in graduate medical sciences, searches for chairs and outstanding research scientists, development of new clinical programs, implementation of an asset and investment management Committee One 10 Academic Year 2005-2006 Self-Study Report system in oversight of aggressive building and capital investment programs The momentum and collegial engagement should be sustainable following lessons learned in the winter and spring of 2006 Is the governance structure appropriate for an institution of this size and characteristics? The governance structure at the collegiate, USF Health, and university levels with oversight and direction of policy and strategic direction by the Board of Trustees is appropriate with the intent for deliberative processes, evaluation, and balances necessary to assure the maintenance of academic, educational, and research goals Concerns center upon the need to assure the balance between collegial deliberation and advice and the drive for expedience, targets of opportunity, and speed inherent to the redesign of the current administration to a model more fundamental to execution of business principles as the entire enterprise is engaged in fundamental reengineering of the corporate “DNA.” Enhanced communication has occurred; nevertheless, lingering concerns remain Describe any situations that require review by or approval of the school’s governing board prior to taking action.” The Board of Trustees of the University of South Florida has the fiduciary responsibility for approval of program changes and overall oversight of the educational, clinical service, and research and scholarly programs of the College of Medicine as one of the constituent colleges of the university Specific responsibilities relevant to the College of Medicine include the following: (1) establishing degree programs up through master's level (2) granting tenure (3) collective bargaining (4) acquiring and leasing real property (5) using, maintaining and controlling university owned or controlled buildings, grounds, property and equipment (6) governing use of names/trademarks (7) creating sponsored research divisions (8) establishing student enrollment and financial assistance policies (9) approving the university's budget and submitting legislative budget requests (10) establishing personnel programs for all university employees (11) accounting for expenditures of all state, local, federal and other funds (12) developing cost-effective information systems and (15) developing university-wide accountability, campus master and strategic plans The vice president for Health Sciences/dean of the College of Medicine who concomitantly serves as provost or chief academic officer for USF Health (Nursing, Medicine, and Public Health) has very effectively gained the confidence of the Board of Trustees and the two major subgroups of the board The first is the Health Sciences Center sub-group and the second is Campus and Academic Environment Some major achievements relate to the authorization of substantial bond financing by university for the construction of the Centers for Advanced Health Care (with guarantee by USFPG – the College of Medicine Practice Plan), approval of a new corporate entity for the delivery of Advanced Medical Learning as an entrepreneurial private sector investment, new departments in Orthopedics and Dermatology, and enhanced development activities Relations are considered both effective and collegial with the Board of Trustees Evaluate the relationship of the medical school to the university and clinical affiliates with respect to: a The effectiveness of the interactions between medical school administration and university administration b The cohesiveness of the leadership among medical school administration, health sciences center administration, and the administration of major clinical affiliates Committee Response: USF COM does not own a teaching hospital USF COM has already established relationships with many area hospitals to achieve its educational mission In addition, relationships with other area institutions are being explored to augment teaching and research programs USF Health is building three state-of-the art teaching centers The Centers for Advanced Healthcare will be designed to integrate cost-effective and high-quality patient care in an environment designed to assure patient safety These centers will integrate information technologies designed to improve patient care Students will be Committee One 11 Academic Year 2005-2006 Self-Study Report an integral part of the Centers for Advanced Healthcare learning in an environment well suited to equip them with the skills needed for patient care and research in the coming years Moreover, a simulation center, the Center for Advanced Medical Learning and Simulation, is being built on the main campus which will enhance student learning and allow students the opportunity to develop patient skills before entering into the clinical arena Tampa General Hospital is a 975-bed tertiary care center that provides care for a wide variety of medical problems including a level trauma center, level neonatal intensive-care unit, burn unit, stroke program, neurosciences intensive care unit, high-risk obstetrics and maternal-fetal medicine, medical and cardiac care units, rehabilitation center, and solid organ transplantation Dean Klasko has a close working relationship with the President and CEO of Tampa General Hospital Dean Klasko is a member of Tampa General Hospital’s governing board, the Florida Health Sciences Board USF Health faculty are represented among the medical staff officers (2 of positions), department chairs (7 of 14 positions), and on the Medical Executive Committee at Tampa General Hospital (9 of 21 positions) USF Health physicians are well represented on important hospital committees including Pharmacy & Therapeutics, Professional Credentials, Critical Care, and Surgical Suites committees USF Health physicians hold numerous medical directorships at TGH – medical ICU, neurosciences ICU, surgical ICU, neonatal ICU, burn ICU, sleep laboratory, infection control, and vascular access team However, despite the extensive contributions of College of Medicine faculty and students to the financial success of TGH, it should be noted that fiscal support for the educational, research and clinical service missions of the College of Medicine is woefully inadequate As a major education and clinical partner of the College of Medicine engaged in enhancing healthcare education in the Tampa Bay region, TGH should provide a substantially greater financial contribution to enhance the various missions of the College of Medicine faculty and students The H Lee Moffitt Cancer Center is a National Cancer Institute designated Comprehensive Cancer Center located on the campus of the University of South Florida In addition to a large outpatient clinic (over 200, 000 visits per year), the center includes a 162-bed specialty hospital (over 6000 admissions per year) The center is organized around fourteen interdisciplinary clinical programs (e.g., Thoracic Oncology, Cutaneous Oncology, and Gastrointestinal Oncology) which encompass patient care, clinical research, education and a number of basic and applied research programs (e.g., Molecular Oncology, Immunology, Drug Discovery, and Experimental Therapeutics) The Cancer Center has the largest blood and marrow transplant program in the southeast When Dean Klasko arrived at the USF COM, there was significant tension between the leadership of Moffitt Cancer Center and the COM One of Dean Klasko’s most urgent priorities was to diffuse this potentially volatile situation After countless meetings with Moffitt Cancer Center administrators and USF COM faculty members, this relationship has been restored, and the COM enjoys a much enhanced partnership with the Moffitt Cancer Center All Children’s Hospital is a 216-bed children’s hospital located in St Petersburg, Florida ACH houses a 60-bed neonatal intensive care unit as well as two pediatric intensive care units In addition to providing general pediatric services, ACH is known for its programs in heart and kidney transplantation, bone marrow transplantation, cystic fibrosis, immunology, genetics, neurosurgery, and care of complex craniofacial disorders The ACH Specialty Care Of Tampa is located across the street from the USF campus and includes outpatient clinics in general and subspecialty pediatrics, rehabilitation services, diagnostics, and an outpatient surgery center The USF Chair of Pediatrics is an ex officio member of the ACH boards which are the following: Foundation, Hospital and Health System Dr Robert Nelson, Chair of Pediatrics, is a voting member He is also a member of the Hospital medical staff executive committee USF has a voice in the ACH decision making process Dr Nelson meets twice monthly with the hospital CEO, and there are at least annual meetings between the vice president/dean and ACH leadership including strategic planning There is an oversight committee for the endowed chairs with membership from ACH and USF In general the system is designed to promote communication Committee One 12 Academic Year 2005-2006 Self-Study Report Two veterans’ medical centers are affiliated with USF Health The James A Haley Veterans Administration Hospital located in Tampa is a 327-bed tertiary care teaching hospital with a 180-bed nursing home unit In addition, there is a 60-bed spinal cord unit, a 50-bed psychiatric unit, and a 42-bed rehabilitation center The hospital and its satellite clinics comprise the busiest veterans’ medical center in the nation serving a veteran population of over 435,000 There are 90 researchers working on 178 research projects Bay Pines Veterans Hospital is located in St Petersburg, Florida and houses 569 beds with 206 nursing home beds Acute and extended care services in medicine, surgery and psychiatry are provided on site There is also a rehabilitation center on site There are many other affiliated institutions; please see the following list: Bayfront Medical Center Community Clinics Florida Hospital Hillsborough County Medical Examiners Facility Morton Plant Hospital Shriners Hospital for Children Suncoast Gerontology Center University Diagnostic Institute USF Medical Clinics USF Psychiatry Center University Community Hospital Assess the organizational stability of the medical school administration (dean, dean's staff) Has personnel turnover affected medical school planning or operations? Are the number and types of medical school administrators (assistant/associate deans, other dean's staff) appropriate for efficient and effective medical school administration? Committee Response: During the past two years, the appointment of Steven Klasko, MD, MBA as the leader of the College of Medicine has resulted in substantial improvements in the organization stability and effectiveness of the medical school’s administration The administration has adopted a highly effective three-vice dean leadership and management structure that has greatly facilitated development and improvement of the college’s three missions The administrative structure of the Dean’s office together with the leaders of the various academic departments are listed below The major change in the structure of the administration developed by Dean Klasko involved the appointment of a vice dean for Educational Affairs (Paul Wallach, MD), a vice dean for Research and Graduate Affairs (Abdul Rao, MD, DPhil) and a vice dean for Clinical Affairs (Robert Belsole, MD) These three individuals are responsible for both strategic planning and the daily operation of the medical school’s three missions The medical school administration has endured little staff turnover over the past several years Many of the members of the administration have served in their current capacity in the College of Medicine for five or more years which has contributed to both institutional stability and effectiveness The addition of the position of chief operating officer of USF Health has introduced a new, unifying focus to medical school operations and has provided a significant stimulus in areas such as resource management, faculty leadership training and enhancing institution-community relationships Overall, the administrative structure of the medical school is appropriate for an institution of its current size and has the capacity to Committee One 13 Academic Year 2005-2006 Self-Study Report adapt to the current rapid growth of the college and the potential changes in the future growth of medical education in the State of Florida College of Medicine Administrative Staff Dean .………… ….Stephen K Klasko, MD Vice Dean, Educational Affairs …………………………….……….……….Paul M Wallach, MD Vice Dean, Clinical Affairs …….…….….Robert J Belsole, MD Vice Dean, Research Affairs ……………………………… ……Abdul Rao, MBBS, MA, DPhil Senior Executive Associate Dean for Faculty and Academic Affairs … … John S Curran, MD Associate Dean for Clinical Practice………………………… ……….… Enrico Camporesi, MD Associate Dean Quality…………………………….…………… … …….Michael Parsons, MD Associate Dean for Undergraduate Medical Education …………….…………Bryan Bognar, MD Associate Dean for Research …………………………….………….… ……Lynn Wecker, PhD Associate Dean for Graduate Affairs .………… ….Joseph J Krzanowski, PhD Associate Dean for Graduate and Post Doctoral Affairs (Interim…… … Michael J Barber, DPhil Associate Dean for Academic Enrichment………………………….… Deanna Wathington, MD Associate Dean for Student Affairs and Admissions… ………… … Steven C Specter, PhD Associate Dean for Business Affairs and Technology…………… …… Joann M Strobbe, MEd Associate Dean for Diversity Initiatives ………………………… …….Marvin T Williams, PhD Associate Dean for Graduate Medical Education & Veterans Affairs ….…….Peter J Fabri, MD Associate Dean for Continuing Professional Development………… Deborah Sutherland, PhD Assistant Dean for Student Affairs .………….….….Carolyn Nicolosi, MS Assistant Dean for Clinical Outreach ………… … Heidi M Stephens, MD Assistant Dean for Special Projects …………………………… ….………… Karen M Burdash Executive Director of USF Physicians Group…………………………… …Joseph M Jackson Director of Admissions…………………………………………….…….…… …Robert E Larkin Director of Area Health Education Center …………… Cynthia S Selleck, DSN Director of Business Affairs ………………………………………… …………….Jean G Nixon Director of Compliance ………………………………….………….………… Patricia J Bickel University of South Florida College of Medicine: FLORIDA Department and Division or Section Chairs Basic Sciences School of Biomolecular Sciences Departments Molecular Medicine ……………………………………… ….Larry P Solomonson, PhD(Interim) Molecular Pharmacology and Physiology ……………….…….……… …Bruce G Lindsey, PhD Pathology and Cellular Biology .…………… Santo V Nicosia, MD Clinical Sciences Departments/Divisions Anesthesiology …… ……… Enrico M Camporesi, MD Family Medicine ………… … H James Brownlee, MD Interdisciplinary Oncology ……………………………………… … S Clifford Schold, Jr., MD Internal Medicine ……… … …Allan L Goldman, MD Neurology … ……… ….Peter B Dunne, MD Neurosurgery…………………………………………………… …….Harry R van Loveren, MD Committee One 14 Academic Year 2005-2006 Self-Study Report Obstetrics-Gynecology ……………………………………………………… David L Keefe, MD Ophthalmology ……….……… Peter R Pavan, MD SMART Program ………….… Lawrence J Lemak, MD Otolaryngology ………… Thomas V McCaffrey, MD, PhD Pediatrics ….………… Robert M Nelson, Jr., MD Physical Therapy, School of ………………W Sandy Quillen, PhD Psychiatry and Behavioral Medicine ….………… Francisco Fernandez, MD Radiology … ….……Martin L Silbiger, MD (Interim) Surgery…………………………………………………………………….….Richard C Karl, MD III Analysis of Recommendations and Deficiencies Relevant to Committee as Identified by Most Recent LCME Review in 1999  Steps taken to address problems of interim leadership, faculty attrition, residency program probation, and legal issues in the Department of Ophthalmology Committee Response: The Department of Ophthalmology is currently under the leadership of Dr Reed Pavan who was appointed in 1999 All the issues concerning leadership, faculty attrition, residency problems and legal issues in the Department of Ophthalmology have been resolved Survey Team Report: While not constituting violations of accreditation standards, there are opportunities for improvement in some areas:  There currently is no process for the periodic review of departments Committee Response: The College of Medicine has implemented a process of annual departmental reviews that are begun at the level of the faculty and chair An annual report of each department is generated and subsequently evaluated by the dean and his administration Chairs receive feedback regarding their department’s performance IV Major Changes Since Last LCME Review in 1999 None V Areas of Strength    The College of Medicine has re-structured the administrative component of the institution to provide strong leadership and direction to the college’s new directions in teaching, research and service USF Health is constructing two Centers for Advanced Healthcare which will include outpatient surgery on the North campus, diagnostics, and pathology services in addition to outpatient clinic services USF Health is exploring affiliation agreements with other area institutions to achieve its goals in research and education – Pepin Heart Institute at University Community Hospital, St Joseph’s Hospital research unit, etc Committee One 15 Academic Year 2005-2006 IV Self-Study Report Areas of Concern and Challenges   VII Lack of a university-owned teaching hospital Potential conflicts between the administrative focus of our affiliated institutions and USF Health’s teaching and research missions Review of Compliance with Established LCME Standards IS-1 Each medical school must engage in a planning process that sets the direction for the institution and results in measurable outcomes To assure ongoing vitality and successful adaptation to the rapidly changing environment of academic medicine, schools need to establish periodic or cyclical institutional planning processes or activities Planning efforts that have proven successful in medical schools and other professional or business milieus typically involve the definition and periodic reassessment of both short-term and long-range goals for the successful accomplishment of institutional missions By framing goals in terms of measurable outcomes wherever circumstances permit, a school can more readily track progress toward their achievement The manner in which a school engages in institutional planning will vary according to available resources and local circumstances, but all schools should be able to document their vision, mission, and goals; evidence indicating their achievement; and strategies for periodic or ongoing assessment of successes and unmet challenges Committee Response: A variety of meetings of faculty and staff together with the administration and the formation of Strategic Work Groups (SWGs) has resulted in a clearly defined strategic plan that outlines the direction of the institution over the next five years The 2005-2006/2009-2010 College of Medicine Strategic Plan presents clear objectives and courses of action that are designed to enhance all three missions of the college The strategic plan specifically addresses the areas of education, research, clinical programs, faculty and staff development, institutional resources and organizational culture IS-2 A medical school should be part of a not-for-profit university or chartered as a not-for-profit institution by the government of the jurisdiction in which it operates Accreditation will be conferred only on those programs that are legally authorized under applicable law to provide a program of education beyond secondary education Committee Response: The medical school is an integral part of the University of South Florida, one of the member institutions of the State of Florida University system IS-3 If not a component of a regionally accredited institution, a U.S medical school must achieve institutional accreditation from the appropriate regional accrediting body The LCME is recognized by the U.S Department of Education as an accrediting agency for educational programs, specifically for the accreditation of medical education programs leading to the MD degree Because the LCME is not recognized as an institutional accrediting agency, it lacks standing to accredit stand-alone medical schools as institutions of higher education Committee One 16 Academic Year 2005-2006 Self-Study Report Institutional accreditation is granted by regional accrediting agencies, and is required to qualify for federal financial assistance programs authorized under Title IV of the Higher Education Act Some regional accrediting bodies grant “pre-accreditation” as a first step to achieving full accreditation In such circumstances the attainment of pre-accreditation status would meet the requirements of this standard Committee Response: The University of South Florida College of Medicine is a fully regionally accredited institution for the delivery of medical education programs IS-4 The manner in which the medical school is organized, including the responsibilities and privileges of administrative officers, faculty, students and committees must be promulgated in medical school or university bylaws Committee Response: The organization of the medical school is governed by the Bylaws of the College of Medicine Faculty Council which describes the roles and responsibilities of the faculty and the different members of the administration These bylaws are continuously examined and revised to reflect any changes in college governance and to adapt to changes in institutional priorities IS-5 The governing board responsible for oversight of the medical school must have and follow formal policies and procedures to avoid the impact of conflicts of interest of members in the operation of the school, its associated hospitals, or any related enterprises Committee Response: The College of Medicine is governed by the Board of Trustees and the president of the University of South Florida IS-6 Terms of governing board members should be overlapping and sufficiently long to permit them to gain an understanding of the programs of the medical school There must be formal policies and procedures to avoid the impact of conflicts of interest, such as the requirement that a board member recuse him/herself from any discussion or vote relating to a matter where there is a potential for a conflict of interest to exist The school also must provide evidence (for example, from board minutes, annual signed disclosure statements from board members) that these policies and procedures actually are being followed Some conflicts related to personal or pecuniary interests in the operation of the school may be so pervasive as to preclude service on the governing board Committee Response: The terms of office of members of the Board of Trustees are years and membership is staggered to maintain continuity "The Florida Board of Governors is established by sec 7(d), Art IX of the Florida Constitution and is a public body corporate comprised of seventeen (17) members; fourteen (14) citizen members appointed by the Florida Governor and subject to Senate confirmation and the Commissioner of Education, the chair of the advisory council of Florida university faculty senates and the president of the Florida university student associations Its constitutionally established duty is to operate, regulate, control and be fully responsible for the management of the publicly funded state university system Florida Statute Sec 1001.70, 1001.705(b) (2005) Currently, operational responsibilities have been further legislatively delegated to local university board of trustees, also Florida public bodies corporate Florida Statute Sec 1001.71, 1001.72 and 1001.74(2) (2005) The University of South Florida (USF) Board of Trustees is Committee One 17 Academic Year 2005-2006 Self-Study Report comprised of thirteen (13) trustees, six (6) of whom are citizen members appointed by the Governor and five (5) by the Florida Board of Governors Eleven (11) of the trustee appointments are subject to confirmation by the Florida Senate The remaining two (2) trustee positions are held by the President of the USF Faculty Senate and the President of the USF Student Government who are ex officio voting members The USF Board of Trustees is specifically legislatively authorized to govern the university Florida Statute Sec 1001.74(2) (2005) The university president serves as corporate secretary of the board of trustees and is responsible to the board for the operation and administration of the university and for setting the agenda for meetings of the board of trustees in consultation with its chair Florida Statute Sec 1001.74(4), 1001.75 (2005) The USF Board of Trustees, since its establishment in 2001, has proved to be of appropriate size and structure to govern this university a large, metropolitan, complex and rapidly growing institution for all organizational areas, including, but not limited to (1) establishing degree programs up through master's level (2) granting tenure (3) collective bargaining (4) acquiring and leasing real property (5) using, maintaining and controlling university owned or controlled buildings, grounds, property and equipment (6) governing use of names/trademarks (7) creating sponsored research divisions (8) ensuring student access to general education courses (9) establishing student enrollment and financial assistance policies (10) establishing student admission and code of conduct policies (11) establishing student fees (12) approving the university's budget and submitting legislative budget requests (13) establishing personnel programs for all university employees (14) accounting for expenditures of all state, local, federal and other funds (15) developing cost-effective information systems and (16) developing university-wide accountability, campus master and strategic plans Florida Statute Sec 1001.74 (2005) In fulfilling its governing role, the USF Board of Trustees has acted primarily as a policy-making body-setting and establishing general oversight guidelines to facilitate implementation and administration of the various enumerated subject matter areas Because USF's President is statutorily charged with operating and administering the university, Florida Statute Sec 1001.75(2005), and she has further delegated the day-to-day operations of the university's College of Medicine to the Dean of that College, there are few daily operational College of Medicine items requiring formal action by the Board of Trustees As seen from the list above, among those matters requiring Board action would be (1) establishing new degree programs (2) awarding tenure (3) acquiring real property (4) establishing student fees IS-7 Administrative officers and members of a medical school faculty must be appointed by, or on the authority of, the governing board of the medical school or its parent university Committee Response: Officers of the medical school are appointed by the president of the university and approved by the Board of Trustees Faculty are appointed by the dean of the medical school and approved by the president of the university Tenure decisions are approved by the Board of Trustees IS-8 The chief official of the medical school, who usually holds the title “dean,” must have ready access to the university president or other university official charged with final responsibility for the school, and to other university officials as are necessary to fulfill the responsibilities of the dean’s office Committee Response: The dean of the College of Medicine and the university president meet frequently with members of the president’s cabinet to fulfill the responsibilities of his office Committee One 18 Academic Year 2005-2006 Self-Study Report IS-9 There must be clear understanding of the authority and responsibility for medical school matters among the vice president for health affairs, the dean of the medical school, the faculty, and the directors of the other components of the medical center and university Committee Response: The same individual holds both offices of vice president for Health Affairs and dean of the College of Medicine which provides consistency of authority, responsibility and leadership IS-10 The dean must be qualified by education and experience to provide leadership in medical education, scholarly activity, and care of patients Committee Response: The current dean of the Medical School has had a diverse career within academic medicine and is eminently qualified to lead an academic medical institution IS-11 The medical school administration should include such associate or assistant deans, department chairs, leaders of other organizational units, and staff as are necessary to accomplish the missions of the medical school There should not be excessive turnover or long-standing vacancies in medical school leadership Medical school leaders include the dean, vice/associate deans, department chairs, and others where a vacancy could negatively impact institutional stability, especially planning for or implementing the educational program Areas that commonly require administrative support include admissions, student affairs, academic affairs, faculty affairs, graduate education, continuing education, hospital relationships, research, business and planning, and fund raising Committee Response: The College of Medicine has a clearly defined group of associate and assistant deans with defined responsibilities Each academic department is led by a chairperson with adequate support staff to maintain and enhance the department’s mission The college administration is moving rapidly to resolve any leadership issues The college is also focusing on enhancing support areas to improve the college’s effectiveness IS-15 All medical school faculty members should work closely together in teaching, research, and health care delivery Because the education of both medical students and graduate physicians requires an academic environment that provides close interaction among faculty members, those skilled in teaching and research in the basic sciences must maintain awareness of the relevance of their disciplines to clinical problems Conversely, clinicians must maintain awareness of the contributions that basic sciences bring to the understanding of clinical problems These reciprocal obligations emphasize the importance of collegiality among medical school faculty across disciplinary boundaries and throughout the continuum of medical education Committee Response: Extensive committee deliberations, analyses by Strategic Work Groups, town-hall meetings and a spirit of shared governance by the administration, have resulted in the generation of a united and cohesive faculty that share responsibility for enhancing and effectively integrating the education, research and clinical service missions of the college Committee One 19 Academic Year 2005-2006 VIII Self-Study Report Recommendations, Possible Solutions and Strategies None IX Issues of Concern Relevant to Other Committees None X Attachments None XI Narrative of Process The members of the committee met extensively over a period of five months to define the goals of the committee and to discuss responses to the various sections of the report assigned to the committee The final conclusions were reviewed and edited by all committee members XII Database Accuracy Database section included the required LCME database elements The committee reviewed the sections appropriate to our deliberations The accuracy of the databases was confirmed through committee discussions XIII Committee Membership Michael Barber, DPhil, Self-Study Committee Chair Professor, Molecular Medicine Interim Associate Dean, Office of Graduate & Postdoctoral Affairs Faculty Senate, President-Elect Michael Alberts, MD, MBA Professor, Interdisciplinary Oncology Sally Houston, MD Professor, Internal Medicine Kendall F Morris, PhD Associate Professor, Molecular Pharmacology & Physiology Robert M Nelson, Jr., MD, MS Professor & Chair, Pediatrics Philip Shenefelt, MD Associate Professor, Internal Medicine Committee One 20 Academic Year 2005-2006 Self-Study Report Martin Silbiger, MD, MBA Professor & Chair, Radiology Chief, Moffitt Radiology John Curran, MD, Administrative Liaison Senior Executive Associate Dean, Academic & Faculty Affairs Patricia Haynie, PhD, Administrative Liaison Associate Vice President, Strategic Planning, Analysis & Operations, USF Health Committee One 21 ... corporate secretary of the board of trustees and is responsible to the board for the operation and administration of the university and for setting the agenda for meetings of the board of trustees in... faculty, and the directors of the other components of the medical center and university Committee Response: The same individual holds both offices of vice president for Health Affairs and dean of the... Self-Study Report Recommendations, Possible Solutions and Strategies None IX Issues of Concern Relevant to Other Committees None X Attachments None XI Narrative of Process The members of the committee