"Reflections on 2010"

This is a time of year for individual reflection. Looking back over the past year, personally and professionally, what can we learn from our achievements and mistakes?

The same applies to organizations like UF&Shands. Reflecting on the past year, organizationally and as a community, what have we accomplished and what have we learned? This issue of On the Same Page addresses this question. In the next issue, we will take a look at the year ahead.

Before I proceed, I want to express my tremendous sense of honor and privilege for the opportunity to play a role in charting the course for health care and health sciences at this great University. I greatly appreciate the trust and guidance of President Machen, and the support that I have received from so many across the entire Health Science Center and Shands health system. The extraordinary talent and commitment of our faculty, staff and students, and their flexibility and enthusiasm in responding to change, have been responsible for the stellar progress we have made in such a brief period of time, and will catapult us ahead.

Reflections on 2010

During this past year we created a new governance structure and completed a comprehensive strategic plan, both of which have already yielded concrete improvements in our clinical, research and educational programs.

Governance: In September, following a plan envisioned by President Machen and approved by the UF Board of Trustees, the Shands Boards in Gainesville and Jacksonville agreed to restructure themselves as "sister" entities. Until this point, Shands Jacksonville had been a subsidiary of the Gainesville hospital, i.e., Shands Teaching Hospital and Clinics (STHC). UF retains governance of both hospitals under the new arrangement. As the President's designee, I was approved by both Boards as Chair of the Shands Jacksonville and STHC Boards. New Board memberships for both sister hospitals have (or are being) established. A Strategic Cabinet, presented to the UF Board in June 2010 and authorized by both Shands Boards, is being convened to review and advise each Board on strategic issues facing each entity and the system as a whole. Other linkages between the two sister hospitals under the UF umbrella consist of common support services such as information technology, human resources, purchasing, managed care agreements, development and other areas in which common support service leads to system benefits.

This new governance structure has created a distributed model in which UF&Shands, the University of Florida Academic Health Center, carries out its mission on two UF&Shands campuses that are largely independent with regard to day-to-day operations and local strategies, but which come together as a system under the UF umbrella. This distributed model of governance promotes focus and nimble decision-making on each campus in a coherent manner that closely coordinates the academic and clinical efforts of the HSC colleges and hospitals.

The first comprehensive strategic plan for UF&Shands—involving all of its colleges, centers, institutes and hospitals on both campuses—was completed during this past year, and implementation has begun. The overarching theme is Forward Together, which emphasizes the central importance of bringing faculty from the HSC colleges together with administration and staff from the Shands health system to unlock the power of our academic health center. A fundamental goal articulated by the Strategic Planning Cabinet was getting from "us and them" to "we." Over the past year, I think that we've come a long way toward achieving this aim. In addition, key drivers were identified for each our missions, and metrics were defined. Progress is already evident in each area. In addition to this overarching document, individual strategic plans for each college, center and institute, and for the Jacksonville regional campus, were also developed.

Patient care: With respect to our clinical mission, quality is the key driver. Efforts are being marshaled from many different angles in a multiple-pronged attack against threats to highest-quality care.

One important overall measure of safety and quality is the observed:expected (O:E) mortality ratio, as measured by the University HealthSystem Consortium (UHC), a group of 98 peer hospitals across the nation. Given the distribution of diagnoses and risk profiles of the patients in these hospitals, UHC calculates an expected rate of mortality, to which the actual results are compared. At both campuses, significant attention has been devoted to improving our care of patients as measured by this O:E ratio. A hospital-wide ratio of 1.0 means that it is performing as expected, i.e., about in line with peers. This is where Shands at UF was during most of 2008 and through about September 2009. However, due to the superb work of faculty and staff, the O:E ratio has steadily declined at Shands at UF, and is now in the range of 0.7-0.8, i.e., 20%-30% better than expected. At Shands-Jacksonville, the O:E mortality was lower than Shands at UF at the start of the period, and is now in a similar range at about 0.8.

Another key UHC measure of patient care quality and safety is the number of events that would qualify as a "patient safety indicator (PSI)" in a given month. These are events—such as central venous line infections, pressure ulcers, patient falls, and the like—that should be as low as possible. At Shands at UF, due to the efforts of patient care teams that have focused on reducing the number of events in each of these categories, the overall number of PSIs per month has fallen from about 30-35 to 15-20 in the past year. At Shands Jacksonville, the number of PSIs was again lower than UF at Shands at the start of the measurement period, and is now in the range of 15-20 per month as well. There is much left to do in our march toward zero PSIs; at both campuses, we will continue to focus on creating a culture of patient care quality and safety as job 1, extending to every member of our hospital and HSC community, in both Gainesville and Jacksonville, which will naturally yield continued improvement in the O:E mortality ratio, PSI scores and other key measures.

In ambulatory care, quality begins with ready access. In August, we launched GatorAdvantage, which gives employees and family members expedited access—including next-day appointments—to medical providers at UF Physicians and Shands at UF. Shands Jacksonville has had a similar system in place for some time, which will now be extended.

This program is being rolled out in stages: Shands at UF employees on Aug. 23, 2010, HSC faculty and staff on Nov. 15, 2010, and UF "main campus" faculty and staff in February 2011. The flexibility shown by our faculty and staff in such a short time frame has been truly remarkable, and the appreciative response by our employees has been overwhelming—many, many positive testimonials and very few reports of difficulty. New patient appointments from the groups thus far in the program (Shands and HSC) are up 20%-25%.

Also important in the highest-quality experience for our patients is the alignment of clinical programs with clinical facilities, both inpatient and ambulatory. In May we announced plans for the Shands Hospital for Children and Women, a reshaping of existing space in the North Tower to create a contiguous four-floor, 175-bed, family-friendly hospital with its own entrance, lobby and emergency department. The first phase of this project is the Pediatric Emergency Department, which will open in July 2011. This project is part of a larger idea in which space for each inpatient specialty program is integrated in a contiguous area and aligned with clinical practice. This has already been accomplished for oncology patients in the Shands Cancer Hospital, and plans are underway for our patients who require neuromedicine, cardiovascular, musculoskeletal and organ transplant services.

The strategic plan calls for two approaches to ambulatory care—aggregation of specialty services at UF&Shands central locations, and distribution of primary care sites throughout the community close to where people live and work. We recently announced that we will build a new UF&Shands primary care center on Gainesville's east side, on North Main Street near Northeast 16th Avenue, replacing and expanding the Family Medicine practice location at Southeast 4th Avenue. Additional primary care centers are being considered in other parts of the community. These primary care centers will foster improved outpatient management of chronic conditions, giving our patients the tools to maintain their health and stay out of the hospital.

One area of specialty service aggregation will take place on our 39th Avenue parcel near I-75, where we already operate Shands Vista and Shands Rehab Hospital. We will begin with a 100,000-square-foot medical office building that will house nine specialty practices, including cardiology, dermatology and skin cancer, geriatrics, neurology, pain, plastic surgery, psychiatry, reproductive endocrinology and in vitro fertilization, and women’s health. Design is in progress and construction will begin in September 2011.

In Jacksonville, a third building was added to the suburban Emerson campus. This 30,000-square-foot building expands the Emerson campus to 90,000 square feet of clinical space. A new state-of-the-art imaging center was opened in the spring and an expanded women’s center was opened in the summer. The Emerson campus houses a joint-ventured surgery center and numerous other UF&Shands clinical services. The primary care network in Jacksonville continues to grow. Six locations in the urban core were awarded medical home certification by the NCQA. These are the only academically affiliated primary care locations in Florida to achieve this certification.

New Small Animal Hospital: As described in my last newsletter, UF’s new Small Animal Hospital at the College of Veterinary Medicine opened for business Nov. 1. This $58 million, 100,000-square-foot full-service hospital is wonderful example of alignment between clinical facilities and clinical programs. It is not only a beautiful building, with a three-story atrium serving as the reception area for animal patients, but a world-class clinical and educational facility that contains specialty service areas with state-of-the-art technology and numerous innovative designs for education, such as rounds rooms adjacent to each specialty service. As Dr. Glenn Hoffsis, dean of the College of Veterinary Medicine, states: "Just as in human medicine, when we deliver on our commitment to excellent patient care and an exceptional client experience on each and every visit, every other objective, such as great teaching and research, falls into place."

Regional strategy: As a quintessential college town, Gainesville is a wonderful place to live and work. Through the lens of health care reform, however, we must broaden our perspective to plan for the regionalization of health care delivery, and create partnerships that will benefit the population we serve. From this perspective, we developed partnerships with two health care entities this past year: Health Management Associates (HMA) and Orlando Health.

After giving careful consideration to our three rural hospitals—Shands Lake Shore, Shands Live Oak and Shands Starke—which we had run since 1996, we reluctantly concluded that we did not have the capital availability or level of management focus needed to operate these hospitals effectively, and that operation of these hospitals was not part of our core mission as an academic health center. Therefore, with support of the Shands Board, and under the leadership of Shands CEO Tim Goldfarb, we divested 60% of these hospitals in August to a joint venture company in which we share ownership with HMA, a company that is known for its excellence in the operation of rural hospitals. This has worked out well for HMA and Shands, and more importantly, for the patients and communities served by these three hospitals. For example, since the transaction was finalized, there has been significant capital investments in these hospitals—including imaging equipment (an open MRI and a CT scanner), a new telemetry system, surgical equipment and a new fetal monitoring system—which we could not have done had we continued full ownership.

Another important step in regional strategy was the Memorandum of Understanding announced with Orlando Health to pursue an affiliation around key areas of clinical service—pediatric and women's health, cardiovascular, neuromedicine, organ transplantation and cancer—as well as clinical and translational research, health science education and graduate medical education. Teams made up of physicians and administrators from both health systems are now giving shape to this affiliation. The overall goal is to make best use of the resources of both health systems to provide a rational approach to regionalized health care for the communities we serve.

Research: In research, the driver is to reach high. In working with the deans in all the HSC colleges, and with the center and institute directors, we have focused on providing research infrastructure that leads to greater scientific productivity among our existing faculty, and on recruiting high-impact investigators who bring established research programs with them to Florida and who then develop these programs further.

The early results are quite spectacular, although we must be cautious because some of the grant funding is from the time-limited (two-year) American Recovery and Reinvestment Act of 2009 (ARRA), and because the future of NIH funding in general is uncertain. In FY09, total NIH funding across all HSC colleges (including Jacksonville) was $112 million, of which $104 represented the base of ongoing funding and $8 million was from ARRA. In FY10, total NIH finding zoomed up to $171 million, representing a base of $118 million, plus $53 million from ARRA. We have examined carefully the funding of grants that will continue beyond the end of ARRA and estimate that base NIH funding in FY11 will continue to climb, probably to a range of $130 million to $135 million. This represents tremendous effort and achievement from our research faculty, and we will do everything we can to help them continue successfully their investigational programs in what will no doubt be an increasingly challenging environment at NIH.

Alignment of facilities and programs is also critical in research. On the heels of opening the Emerging Pathogens Institute in 2009, in May 2010 we dedicated the new Biomedical Sciences Building, a 163,000-square-foot facility that brings together researchers from the colleges of Medicine, Public Health and Health Professions, and Engineering. It houses five interdisciplinary programs: the Center for Translational Research in Neurodegenerative Disease, the Diabetes Center of Excellence, the J. Crayton Pruitt department of biomedical engineering, the Rehabilitation Research Program in the department of physical therapy of PHHP, and the UF Howard Hughes Medical Institute for Undergraduate Science Education. The Biomedical Sciences Building is notable for being the first Gold-level, LEED-certified building at UF, an achievement that recognizes the commitment of UF to assuring that its buildings are sustainable and energy-efficient, and provide a healthy environment for their occupants.

Another interdisciplinary building is now under construction at the Lake Nona "Medical City" campus in Orlando. On Oct. 4, we broke ground on the new UF Research and Academic Center, a $44 million, 100,000-square-foot LEED Gold building that will contain three components: (1) an education wing for the Orlando campus of the UF College of Pharmacy, which currently enrolls 200 students taught by 20 faculty members, now housed at the UF IFAS Mid-Florida Education Center in Apopka; (2) a clinical research wing, to be occupied by satellites of the UF Institute on Aging and the UF Clinical and Translational Science Institute, to run clinical trials with participants in the Orlando area; and (3) the UF Institute of Therapeutic Innovation (ITI), an interdisciplinary program that will house faculty from the colleges of Pharmacy, Medicine and perhaps others such as Engineering. Faculty in the ITI will have appointments and collaborations in scientific departments of the UF colleges, but will live and work in Orlando. This initiative will complement the emerging drug discovery programs at the Sanford-Burnham Medical Research Institute. The goals of the ITI will include identification of new therapeutic targets and optimization of drug candidates for the treatment of the most devastating human diseases, including cancer, cardiovascular disease, diabetes and brain disorders, which can then be tested in human populations through clinical trials supported by the CTSI.

During the past decade, we have been extremely fortunate to add more than 1 million square feet of space for wet-lab investigation in newly constructed research buildings. While we will certainly maintain our commitment to fundamental science and early translational investigation, space is now also needed for the many large clinical research grants that have been received in the recent past, and for funded plans to build infrastructure through our NIH Clinical and Translational Science Institute (CTSI). Approved by the UF Board of Trustees in May, the Clinical and Translational Research Building (CTRB) will be the academic home of clinical and translational science at UF. This 120,000-square-foot building, to be constructed on the site across from Wilmot Gardens on Mowry Road, includes the Institute on Aging, the CTSI headquarters, the Clinical Research Center, faculty members working in biostatistics, epidemiology, health policy, and health services research, and clinical research programs such as those focused on type 1 diabetes and muscular dystrophy. It is being designed to exceed Platinum LEED certification. Construction will commence in June 2011.

Education: In education, the driver is to use our unique combination of colleges and other resources to become a national model for education in the health sciences and health professions. The Strategic Planning Cabinet wanted to ensure that discipline-specific curricular needs for each college are addressed in focused areas of scientific knowledge and patient care skills. Moreover, in graduate study the Cabinet wanted to ensure that our trainees can take advantage of the applied and translational opportunities for biomedical discovery and clinical application. In the planning process that was completed this past year, the Cabinet recognized that many other areas of professional education represent common objectives across colleges.

There is a great opportunity to create a curriculum that provides our students with the experience needed to master key cross-college competencies: interpersonal communication, professionalism, teamwork, system-based knowledge and the evaluation of scientific and clinical evidence. Richard Davidson, M.D., a professor of medicine, was appointed associate vice president, health affairs—interprofessional education. Dr. Davidson is now leading a committee, consisting of the associate deans for education in the six colleges, who are developing an interdisciplinary curriculum for students across the Health Science Center. With students being educated in all of the health sciences and professions, we have a unique opportunity to develop a national model for how to achieve the interprofessional competencies.

As 2010 draws to a close, let me extend my very best wishes to you and your family for the New Year. In the next edition of On the Same Page, we will take a look at the goals and challenges that lie ahead for UF&Shands in 2011.

Forward Together,

David S. Guzick, M.D., Ph.D. Senior Vice President, Health Affairs President, UF&Shands Health System