DEPARTMENTAL REVIEW PROCESS

Ad Hoc Committee Report: 04/07/2003
Approved by the COC and Dean: 05/2003

Background

The Ad Hoc Committee on Departmental Review discussed renewal of a review process for the School of Medicine (SOM). This process began as an initiative of the chairs who designed this process in 1994. Much has changed in academic medicine in the past decade; our committee continues to believe that an external review of each department is appropriate and could be very useful. This process remains voluntary, since there are no SOM By-laws mandating department reviews.

The Committee evaluated the UNM Main Campus Graduate Unit review policies. Main Campus reviews are based upon a departmental self-study and a seven-year external review cycle. Our report is broadly consistent with these policies, but extends into the business of medicine, clinical care, research, and teaching at a number of different facilities. Furthermore, the review process of a department (or a large center) is only one part of a more general review process that also extends to the Dean’s office and to Health Sciences Center.

Despite the additional work and attention to detail, the majority of chairs consider this review process to be worthwhile. Advantages are several fold: (1) self study of the department, (2) collaboration opportunities that had not been recognized, (3) additional support from the Dean’s office after more objective information was gathered to support specific needs, (4) advice to the chair provided informally by external reviewers, and (5) information for recruitment of the next chair.

Purpose

The purpose of a review is to constructively evaluate a department to:

  1. Correlate department direction and goals with those of the medical school and Health Sciences Center
  2. Identify essential resources that the department may need in order to meet the goals of the medical school and Health Sciences Center.
  3. Identify areas for improvement and supply constructive suggestions.
  4. Determine levels of teamwork and communication and identify barriers within the department and between departments.
  5. Ensure that existing resources in the department are being used effectively

An adequate review process should not stand alone but result in the development of a plan that, when successfully implemented, will result in a more effective and efficient department as defined by the following outcomes:

  • Clarity of who does what and what is expected
  • Enhanced communication, both vertical and horizontal, within and outside the department
  • Improved management of the business of medicine
  • A more motivated workforce
  • More teamwork in teaching, research and patient care
  • More effective teaching
  • Quality and more efficient patient care
  • Organized research with a focus on institutional objectives
Methodology of the Review

General. Departments or large centers should be reviewed at least every seven years. The review process of all departments in the medical school will be stepwise rather than simultaneously. The order will be determined by the Dean, with a master schedule being sent to each chair. Since the primary goal of this review is to improve the department and to meet the goals of the medical school and Health Sciences Center, reviews will be done regardless whether a department has a permanent chairperson. The review will include an assessment of the chair's management. It will be external and separate from each department's annual internal review.

Internal audit and data collection. All departments will collect critical data for a concise and more uniform review by external reviewers. Data to be collected by each department will be done in a uniform manner to allow comparison between departments within and outside the school. Information relative to all areas at which the department functions (e.g. University Hospital, CRTC, VA, , Carrie Tingley, etc.) will need to be provided. The following minimum information needs to be collected before the review:

  1. List of departmental vision, mission, and goals
  2. 1-2 page departmental history
  3. 3 or 5 year strategic plan as it relates to the school's and hospital's plans
  4. SWOT analysis (strengths, weaknesses, opportunities, threats) as prepared by the chair
  5. Reports used in department annual reviews with the Dean for at least 3 years
  6. Key financial indicators from UPA
  7. Pres Ganey survey results with trends, student evaluation (MS, GME, Grad & Post-doc)
  8. Market share and referral base
  9. List of average salaries compared with AAMC current data
  10. List of peer review publications for each of last 5 years and results of citation index
  11. List of grants (federal, industrial, foundation)
  12. Recent accreditations or reviews (JCAHO, NIH reviews or site visits, etc)
  13. Results of any internal reviews
  14. Anonymous evaluation by students (Phase I, II, III), residents and graduate students
  15. Residency and fellowship programs
    List of individuals by year
    Accreditation results
    Residency reviews
  16. Graduate students and post-doctoral fellows
    List by year, mentor, and location
    Progress toward degree
    Papers, grants
    Teaching load
  17. Allied Health programs
    2-paragraph history
    Number of students
    Accreditation results

External review. The chair provides the names of five potential reviewers from peer institutions from which the Dean will choose two. Compared with one reviewer, two persons from diverse institutions would be more objective and offer a stronger overview for department strategic planning. They would visit the department at the same time and "compare notes" to provide more insight in their report. The external review report should include the following elements:

  1. General description of the review process
  2. Description of the implementation of previous program review recommendations
  3. Summary of the internal data collection and review
  4. Summary of the findings of the external review including: a) summary of the strengths and weaknesses of the department and b) recommendations for program improvement.

Expenses of the external review will be borne by the Dean's office. The costs of internal assessment and assembling data will be the individual department’s responsibility. We estimate that the external review should cost up to $10,000 per department. Therefore, if two departments are reviewed annually, the Dean's office will budget up to $20,000 annually.

Actions to be Taken after a Review

The reviews must be available to the Dean and Vice-President. The goal of the review is to be constructive and to improve the department. Therefore, it would be most beneficial for the results to eventually be open to all departmental faculty. This recommendation is critical, since the departmental faculty are responsible for the department's performance and for improving the program.

As with current policies regarding UNM Main Campus reviews, results of each department review will fall into one of the six categories. The external reviewers should recommend a category, but the final decision on category will be determined by the Dean.

  1. Continue the department and programs with commendation and minor suggestions for improvement
  2. Continue the department and programs with suggestions for future direction
  3. Continue the department and programs with minor adjustments and a one year follow-up report to the Dean and Vice-President.
  4. Continue the department and programs with major adjustments with annual reports to the Dean and Vice-President for a 3-year period.
  5. Place the department and programs on probation with annual reports to the Dean and Vice-President with another external review in 3 years.
  6. Eliminate the department and programs. This will require a vote of the faculty (as per the Faculty Handbook).

After any review, the chair will meet with the Dean to review the results. Eventual outcomes should be a shared responsibility. The chair and Dean may elect to meet with senior leaders in the department to discuss any sensitive issues before presentation to all faculty. The eventual department-specific action plan must be understood and preferably acceptable to all faculty.

With an unfavorable review recommendation (categories 4-6), there must be constructive suggestions given by the reviewers to the chairs. These will be reviewed with the Dean and a timetable of implementation should be specified. The Faculty Handbook clearly indicates that the chair serves at the pleasure of the Dean; however, the Dean must give the Chair regular assessments, and goals.