Developing a sustainable research culture in an independent academic medical center.

Author:Joyce, Jeffrey N.
Position:Report
 
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Introduction

Traditional academic medical centers (AMCs), with a teaching hospital associated with a medical school, have been the home for clinical and translational research for several decades. However, independent academic medical centers (IAMC) which are free-standing hospitals providing residency training are increasingly engaged in translational research. As proposed by Melese (2006, page 2) "AMCs accept a remarkable challenge: to integrate and achieve with excellence four core missions: delivery of healthcare; education and training of future generations of clinicians and investigators; discovery of new knowledge through incisive, decisive research; and the export of knowledge through effective interactions with industry and government. Each mission is critical, and each must be interactive with and respectful of the others". While the addition of the Teaching and Research components is essential to the overall mission of AMCs and IAMCs, these two components also have an impact on their financial and credit profiles. It has been evident for many years that clinical research activities are secondary to the delivery of healthcare in IAMCs, and administrative structures and policies do not support development of the research enterprise (Campbell, Weissman Moy, & Blumenthal, 2001; Oinonen, Crowley, Moskowitz, & Vlasses, 2001). As a consequence these counter balancing needs and values that challenge the ability of IAMCs to grow their research enterprise. It is recognized, therefore, that new strategies are needed in "maintaining academic medicine's integrity and effectiveness in pursuing its vital research mission" (Cohen & Siegel, 2005).

Academic medical centers and teaching hospitals are indispensible to promoting translational research, because of the preponderance of clinical research conducted in these institutions (Dickleret, Korn, D., & Gabbe, 2006; Goldhamer et al., 2009). The clinical research enterprise has been stimulated in academic medical centers through a number of formal and informal mechanisms, but evidence of effectiveness of these mechanisms has been limited to recognition of institutions that rank in the top level of National Institutes of Health (NIH) funding. Even within these institutions, where there is typically protected time for research, a small number of faculty are engaged in clinical trials research (Weston, Bass, E.B., Ford, D.E., & Segal, 2010; Zinner & Campbell, 2009). Despite widely recognized barriers to creating translational research endeavors, the design of systematic approaches to promoting clinical research has been largely limited to these same research-intensive institutions (Rosenblum & Alving, 2011). In two papers, which explored attitudes and beliefs about participation in clinical trials at nonacademic healthcare delivery systems by physicians, Somkin et al. (2005; 2008) also identified barriers that led to a significant mismatch between perceived value of clinical research by physicians and actual participation by physicians in clinical trials. While almost three quarters of cardiologists and oncologists viewed participation in clinical trials as important and valuable, less than 30% actually participated as a clinical trial principal investigator. Barriers to participation included: (1) a mismatch between beliefs of the institutional leaders and clinicians about value of clinical research, (2) lack of adequate skilled support staff (e.g., nurse clinical coordinators), (3) lack of or noninvolvement of research department in clinical trials, (4) lack of dedicated research time for physicians, and (5) lack of secondary support staff (pharmacists, data mangers, statisticians, etc.). The authors did not address strategies to increase clinician principal investigators in clinical trials, or how institutions could support an environment conducive to physician involvement in clinical trials.

This article describes the processes by which a newly established Department of Research focused on promoting research collaborations as a tool to help the a research enterprise grow at an independent academic medical center. Maricopa Integrated Health System (MIHS) is centered in a large metropolitan area with a diverse socioeconomic patient population. The cornerstone of MIHS is Maricopa Medical Center (MMC), a major teaching hospital with a history dating back more than 100 years. MIHS became an independent health care district by voter approval in 2005 and is governed by an elected five-member Board of Directors. As an independent academic medical center, the core missions include medical education and research, with MIHS offering nine residency programs training over 295 residents annually. The Department of Research was established in 2006 to meet several goals, but the driving need was the Accreditation Council for Graduate Medical Education (ACGME)'s review of physician training programs, at MIHS and elsewhere, which demonstrated the vulnerability of programs lacking a credible research component. Another important driving force was MIHS's intention to assume the role of a major university- affiliated teaching hospital and clinical hub for its research partners. The author, the first Director of Research, assumed this position in early 2007. The administrative growth and organizational design of the department is detailed elsewhere (Joyce 2011).

This article is framed in reflective practice (Leitch & Day, 2000; Jacobs, 2012), and aims to use case studies to illustrate an antecedent situation leading to a theory-based strategy and exemplar practice episodes. The antecedent situation was the establishment of the Department of Research within MIHS at a point when growth in the research enterprise was both critical to and defined as part of the mission of the institution. A set of research enterprise drivers was organized as the theoretical framework, which also served as the management framework supporting specific strategies to promote research growth at MIHS. The practice episodes are detailed as case studies, where resources and outcomes were clearly identifiable. The experience of the author in his previous position as Director of a center for Parkinson's disease research, a center without walls, when he was at a research institute framed this core strategy. The core strategy was dependent on forming collaborative ventures with partner institutions

Understanding Research Enterprise Drivers

The predominant reason cited by Somkin et al. (2005; 2008) for a successful research enterprise at an IAMC or nonacademic healthcare delivery system is the alignment of the core values and mission of the system executive leadership and the physician/investigator leaders around the value of the research enterprise. The authors identified the second most important reason as being an active and participative research office or department. From its inception in 2006, the Department of Research worked with the executive leadership to set mission driven goals that focused on the value of the research enterprise. The five specific mission goals were: (1) Service/Access -increase sponsored clinical studies; (2) Quality -reduce clinical study approval time period; (3) Growth -launch new researchers, (4) People -serve on external collaborative research committees; and (5) Financial -increase cost recovery for clinical research operations. The author, as first Director of Research, developed the management framework to translate these goals into a set of research enterprise drivers encore passing three domains: (1) Commercial ventures; (2) Clinical practice; and (3) Civic and Community relationships (Figure 1) which have an impact on other MIHS core missions for MIHS (e.g., medical education). These enterprises drive research growth because of the intersection with, and impact upon, multiple interested parties.

The domain-based management framework is similar to "a combined process methodology/ industrial sector management framework" for university-industry research collaborations discussed by Philbin (2010). Philbin identified three categories in which there are benefits or key drivers that impact university-industry collaborations. The present framework expands the intersections from the similarly defined IAMC (MIHS)-government/industry commercial enterprise to two other enterprises: clinical practice and civic/community. This author identified the interested parties in each enterprise in order to engage them in beneficial research collaborations. The interested parties in the commercial venture enterprise included industry sponsors, federal funding agencies, and foundations. The interested parties in the clinical medicine practice enterprise included physicians, residents, medical and graduate students. The interested parties in the civic and community enterprise included partnering universities, not-for-profit research institutions, and service organizations. Each enterprise has different strategies for growth, development, and engagement, yet they influence each other significantly. Because the execution of the strategies required steep research administration growth and support at MIHS and alignment with other MIHS departments (i.e. information technology, finance and revenue, legal and compliance departments) the Research Department developed an administrative and implementation strategic...

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