Exploring Effective Governance Models in Academic Emergency Medicine Units

Towards Better Governance Towards Better Governance Models for Academic Models for Academic Units/ Units/Depts Depts of EM of EM CAEP working group / panel Academic Symposium 2015 Once you have three people working together you have a governance problem whether you want one or not. It might be a simple agreement on a napkin but it s governance

Governance Panel Members: Governance Panel Members: David Petrie, Chair (Dalhousie U) Jim Christenson, Leadership Working Group Chair (U British Columbia) Ian Stiell, Academic Section Executive Chair (U Ottawa) Gordon Jones (Queens U) Anil Chopra (U of Toronto) Shannon MacPhee (Dalhousie U) Michael Schull (U of Toronto) Alecs Chochinov (U of Manitoba) Margaret Ackerman (McMaster U) John Tallon (U British Columbia) Jennifer Artz (CAEP) Kelly Wyatt (CAEP)

WHAT ARE THE BEST MODELS FOR UNIVERSITY EM WHAT ARE THE BEST MODELS FOR UNIVERSITY EM GOVERNANCE AND ADMINISTRATION? GOVERNANCE AND ADMINISTRATION? To define effectiveness as an outcome of an emergency medicine academic program. To describe current governance and administration models and relate them to the overall effectiveness of the academic unit. To point out variability and gaps across Canada and determine best models to develop, sustain, and grow strong academic programs.

Terms of Reference: Terms of Reference: a) Researching the topic including environmental scans of Canada and U.S., literature review, and interviews of experts. b) Creating recommendations for Canadian Academic EM units, c) Presenting the recommendations at the CAEP 2015 Academic Symposium, d) Publishing the recommendations in CJEM.

Overview: Overview: What is Governance? Two separate but related levels of governance in dept/unit s of EM Why is governance important in the context of Academic Emergency Medicine? If governance is a means to an end, what is the purpose of an Academic Unit / Department of Emergency Medicine and how does that impact governance? What do we know about governance in Canadian EM dept/units across Canada? Questions to reflect upon re your own situation (handout 1). What are the essential elements of good governance in this context? Towards better governance at the Unit/Dept level (handout 2). Why become a full academic department (handout 3). Recommendations

Proposed Flow of presentation: Proposed Flow of presentation: Intro/Background/Framing - Petrie (10 min) Recommendation 1 Recommendation 2 Discussion Handout 1 Environmental scan survey results Importance of good internal governance - Petrie (5 min) Discussion Handout 2 Recommendation 3 To be, or not to be, a Department - Chopra and Chochinov (15 min) Discussion Handout 3 Recommendation 4 Summary Petrie et al Recommendation 5 and 6

Definition of Governance: Definition of Governance: http://iog.ca/ The complexity of governance is difficult to capture in a simple definition . The need for governance exists anytime a group of people come together to accomplish an end . Governance determines who has power, who makes decisions, how other players make their voice heard and how account is rendered.

Who makes what decisions, and how; at the Unit/Dept level and at the FoM/University level?

Inter Inter- -dependent aspects of Unit s effectiveness: dependent aspects of Unit s effectiveness: Leadership Funding Governance

Governance is a Means to an End: Governance is a Means to an End: Patient Care Population Outcomes Education Research Leadership Governance Funding The vision of the CAEP Academic Section is to promote high- quality emergency patient care by conducting world-leading education and research in emergency medicine .

Tripartite Mission: Research, Education, Patient Care: Tripartite Mission: Research, Education, Patient Care:

Provincial Government DoH, DoE Accountabilities to ultimate Payer(s) / Public Legitimacy Legislation Chair/Chief as agent of Hosp/FoM. Hospital privileges/ academic promotion Affiliation agreement vs single AHSC Health Authority, University, FoM Voice Hospital Bylaws Purpose/Mission: Clinical Care, Education, Research Academic Chair Clinical Chief Membership agreements Individual MDs and constituent programs

Provincial Government DoH, DoE Accountabilities to ultimate Payer(s) / Public Legitimacy Legislation Chair/Chief as agent of Hosp/FoM. Hospital privileges/ academic promotion Health Authority, University, FoM Affiliation agreement vs single AHSC Voice Hospital Bylaws Purpose/Mission: Clinical Care, Education, Research Academic Chair Clinical Chief Membership agreements Individual MDs and constituent programs

Provincial Government DoH, DoE Accountabilities to ultimate Payer(s) / Public Legitimacy Legislation Chair/Chief as agent of Hosp/FoM. Hospital privileges/ academic promotion Health Authority, University, FoM Affiliation agreement vs single AHSC Voice Hospital Bylaws Purpose/Mission: Clinical Care, Education, Research Academic Chair Clinical Chief Membership agreements Individual MDs and constituent programs

Provincial Government DoH, DoE Accountabilities to ultimate Payer(s) / Public Legitimacy Legislation Chair/Chief as agent of Hosp/FoM. Hospital privileges/ academic promotion Health Authority, Affiliation agreement vs single AHSC University, FoM Voice Hospital Bylaws Purpose/Mission: Clinical Care, Education, Research Clinical Chief Academic Chair Business Manager Membership agreements Individual MDs and constituent programs

5 Principles of Good Governance: 5 Principles of Good Governance: 1. Legitimacy and Voice Participation, consensus orientation 2. Direction Strategic Vision 3. Performance Responsiveness, Effectiveness, Efficiency 4. Accountability Accountability and Transparency 5. Fairness Equity and rule of law

Governance as Leadership model: Governance as Leadership model: We don t think about or debate governing; we just do it Chait, Ryan, Taylor, 2005. Governance as Leadership

Governance as Leadership in EM: Governance as Leadership in EM: Who makes what decisions, and how? Who makes what decisions, and how? Fiduciary Stewardship of tangible assets (financial and legal obligations) Accountability to senior organizations, payers, partners, stakeholders Accountability to individual members and constituent interests Strategic Set the Unit/Dept s course and priorities (Mission, Vision, Values) Deploy resources accordingly (trade-offs, incentives) Generative (adaptive) Frame problems and make sense of ambiguous situations Evolve, adapt, respond to uncertainty and changing environments

Two Inter Two Inter- -dependent ways to view dependent ways to view Governance in Academic Governance in Academic Depts Depts/Units of EM: /Units of EM: 1. Dept/unit in relation to internal programs/EM physicians? See handout 2 re Top 10 aspects of good internal governance . What does the CAEP academic section survey tell us? How well is your own Dept/unit doing? 2. Dept/unit in relation to the Faculty of Medicine/University? See handout 3 re Why become an Acadmic Department . What does the CAEP academic section survey tell us? How well is your own Dept/unit doing?

Two levels of governance in Academic EM: Two levels of governance in Academic EM: Two levels of governance impacting Unit/Dept performance Full Academic Department Status within University, Faculty of Medicine Division, section, or no status within University, Faculty of Medicine Good Governance of Internal Affairs A B Challenged Governance of Internal Affairs C D

Dont just do it; think about it Don t just do it; think about it

Recommendation # 1: Recommendation # 1: Along with leadership and funding, governance can have an important impact on Academic Unit / Departmental policy development and decision making. Therefore, governance should not be taken for granted. There should be a deliberate approach to governance structures, processes and improvements. See Handout # 1

Recommendation # 2: Recommendation # 2: No two Academic Units / Departments are the same; the ideal governance structure for any given Unit/Dept should be aligned with the local institutional bylaws, organizational cultures, and relative emphasis the Unit/Dept puts on the tripartite mission of academic medicine (patient care, research, and education). See Handout # 1

EM Status and Department vs Other: EM Status and Department vs Other: STATUS OF EM WITHIN THE 17 MEDICAL SCHOOLS 2, 12% Full Department Division/Section Joint Department with FM 3, 18% 8, 47% No Status 4, 23%

Division/Section of EM affiliations: Section / Division Affiliations (n = 4) Medicine 3 Pediatrics 2 Family Medicine (FM) 2 Not Specified 1 Surgery 0

Division Division of EM affiliations: of EM affiliations: N = 3 Divisions (1 Section) Medicine Surgery Family Medicine CCFP-EM Pediatrics FRCP A PEM is with Peds FRCP CCFP-EM B PEM is with Peds FRCP, CCFP-EM? C PEM is with Peds

Sources for financial support across the 17 medical schools Sources for financial support across the 17 medical schools Sources of Support 6 Hospital 7 Practice Plan 10 Ministry of Health / Alternate Funding Plan 17 University Number of Medical Schools

Directors and Assistant Directors Directors and Assistant Directors Clerkship Electives Other UG 5 Funded Electives Directors 16 Funded Clerkship Directors 3 Funded Other Directors 1 Unfunded 2 Funded Clerkship Assistant Directors CCFP- EM RCPSC- EM Off- service 17 Funded Program Directors 14 Funded Program Directors 11 Funded Off- service Directors 10 Funded Assistant Program Directors 10 Funded Assistant Program Directors 1 Unfunded 1 Unfunded

Directors and Assistant Directors: Education Scholarship Directors and Assistant Directors: Education Scholarship EM EM CPD Education Scholarship 4 Funded Directors 8 Funded Directors 4 Funded Directors 1 Unfunded 1 Unfunded

Research and Support Research and Support Resident Research Facilitator Research Director 14 Funded Directors 13 Funded

But what does this say about the best models for But what does this say about the best models for University EM governance (at both levels ): University EM governance (at both levels ): 1. Legitimacy and Voice Participation, consensus orientation 2. Direction Strategic Vision 3. Performance Responsiveness, Effectiveness, and Efficiency 4. Accountability Accountability and Transparency 5. Fairness Equity and rule of law

Recommendation # 3: Recommendation # 3: Internal governance structures govern the relationship between the Academic Unit / Department and the constituent academic programs, and the individual physicians. While modifying to local contexts, Academic Units/Depts should consider implementing the top 10 list of governance principles in their design. See: Top 10 elements of a Good Governance Plan for Depts/Units of Emergency Medicine (Handout # 2).

Recommendation # 4: Recommendation # 4: Divisions and Sections of Emergency Medicine should seek to become Academic Departments as a means to develop, sustain, and grow strong academic programs (provided that careful analysis suggests mutual benefits to Emergency Medicine and the mission of the Medical School). See: Why should EM be an Academic Department (Handout # 3)?

Why should EM be an Academic Department? Why should EM be an Academic Department? Chochinov and Chopra: 10 - 15 minutes dialogue on Why full academic dept status is important and how it has made a difference Why academic performance is the real issue (and full academic dept status may not be necessary for that)

How to become a Department of EM? How to become a Department of EM?

How to become a Department of EM? How to become a Department of EM? 1. Build the respect and reputation of EM over time (especially in research and education) but also, in day-to-day clinical care 2. Articulate a vision of improved patient/population outcomes fostered by excellence in EM education and research (when/where ever possible) 3. Understand the culture of the institution(s) 4. Know the criteria and process of application at your institution 5. Understand the priorities and values of the Dean and the CEO of the Health Science Centre - align the prospective Dept s with these 6. Build coalitions (Especially with the Chair of Medicine, Surgery, Family Medicine, and Pediatrics) emphasize mutual advantages of departmental status

Recommendation # 5 and # 6: Recommendation # 5 and # 6: The CAEP Academic Section should organize and support a consultation service to provide experience, analysis, and advice to Chairs/Heads because there is no how to blue print for an Academic Unit / Department to construct, implement, and improve their governance (at both levels). Many of the leadership/governance/funding issues and challenges facing academic emergency medicine across the country have similar patterns and drivers (even if contexts and details may differ between Universities). The Academic Chair/Heads should establish a formal and regular forum for meeting and sharing experiences/approaches to common issues.

Example Executive Committee: University Head/District Chief 2 Site Chiefs (major teaching hospitals) 3 Academic representatives 2 elected members + Chief Operating Officer