Health care has evolved from a cottage industry to a very complex one constituting nearly one-fifth of the U.S. economy. Large aggregated health care systems have evolved primarily for the purpose of optimizing financial performance by capturing greater market share and taking advantage of economies of scale in care delivery. With the noble intent of providing a broader base of support for the academic mission, academic health centers (AHCs) have followed suit by partnering with community hospitals and organizations with variable prior experience in the education and research arenas. Such a strategy makes good business sense, but it creates challenges for the academic mission. Singular emphasis on physicians' clinical productivity enhances financial margin but often reduces faculty time and effort dedicated to the academic mission. While individual AHC governance is varied, the leadership structure of large aggregated health systems built around an AHC is even more complex and heterogeneous. Yet, to ensure the prosperity of the academic mission, the governance structure of such health care systems is of critical importance. Preservation of academic oversight of the faculty practice plan, a unifying central focal point of organizational decision making, and genuine physician leadership are three overarching governance characteristics that strengthen the prosperity of the academic mission within large aggregated health systems. Despite the heterogeneous nature of academic health system governance, these critical components of organizational leadership structure facilitate support of a robust academic mission. Understanding these principles and objectives of governance is essential for critical faculty engagement in AHC leadership activities.

Governance of Academic Health Centers and Systems: A Conceptual Framework for Analysis

Importance The American College of Surgeons National Accreditation Program for Rectal Cancer (NAPRC) promotes multidisciplinary care to improve oncologic outcomes in rectal cancer. However, accreditation requirements may be difficult to achieve for the lowest-performing institutions. Thus, it is unknown whether the NAPRC will motivate care improvement in these settings or widen disparities. Objectives To characterize hospitals’ readiness for accreditation and identify differences in the patients cared for in hospitals most and least prepared for accreditation. Design, Setting, and Participants A total of 1315 American College of Surgeons Commission on Cancer–accredited hospitals in the National Cancer Database from January 1, 2011, to December 31, 2015, were sorted into 4 cohorts, organized by high vs low volume and adherence to process standards, and patient and hospital characteristics and oncologic outcomes were compared. The patients included those who underwent surgical resection with curative intent for rectal adenocarcinoma, mucinous adenocarcinoma, or signet ring cell carcinoma. Data analysis was performed from November 2017 to January 2018. Exposures Hospitals’ readiness for accreditation, as determined by their annual resection volume and adherence to 5 available NAPRC process standards. Main Outcomes and Measures Hospital characteristics, patient sociodemographic characteristics, and 5-year survival by hospital. Results Among the 1315 included hospitals, 38 (2.9%) met proposed thresholds for all 5 NAPRC process standards and 220 (16.7%) met the threshold on 4 standards. High-volume hospitals (≥20 resections per year) tended to be academic institutions (67 of 104 [64.4%] vs 159 of 1211 [13.1%];P = .001), whereas low-volume hospitals ( Conclusions and Relevance Hospitals least likely to receive NAPRC accreditation tended to be community institutions with worse survival outcomes, serving patients at a lower socioeconomic position. To possibly avoid exacerbating disparities in access to high-quality rectal cancer care, the NAPRC study findings suggest enabling access for patients with socioeconomic disadvantage or engaging in quality improvement for hospitals not yet achieving accreditation benchmarks.

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Evaluation of Access to Hospitals Most Ready to Achieve National Accreditation for Rectal Cancer Treatment

Purpose:This discussion paper argues that holding independence as the central goal for rehabilitation has limitations that hinder successful outcomes. It shows why autonomy and social engagement sh...

Is independence enough? Rehabilitation should include autonomy and social engagement to achieve quality of life:

Preparedness measures for the anticipated surge of coronavirus disease 2019 (COVID-19) cases within eastern Massachusetts included the establishment of alternate care sites (field hospitals). Boston Hope hospital was set up within the Boston Convention and Exhibition Center to provide low-acuity care for COVID-19 patients and to support local healthcare systems. However, early recognition of the need to provide higher levels of care, or critical care for the potential deterioration of patients recovering from COVID-19, prompted the development of a hybrid acute care-intensive care unit. We describe our experience of implementing rapid response capabilities of this innovative ad hoc unit. Combining quality improvement tools for hazards detection and testing through in situ simulation successfully identified several operational hurdles. Through rapid continuous analysis and iterative change, we implemented appropriate mitigation strategies and established rapid response and rescue capabilities. This study provides a framework for future planning of high-acuity services within a unique field hospital setting.

Development of Rapid Response Capabilities in a Large COVID-19 Alternate Care Site Using Failure Modes and Effect Analysis with In Situ Simulation.

Care Delivery for Male Infertility: The Present and Future

The health care system in the United States is undergoing substantial consolidation through mechanisms ranging from mergers and acquisitions to institutional affiliations tosingleserviceagreements,oftenwithexpectationsofimproving the safety and quality of care. However, there has beenlittleevaluationoftherisksthatsystemexpansionhas on patients.1,2 In a partnership between a medical liability insurer(CRICO/RiskManagementFoundation)andahealth systems research center (Ariadne Labs), we analyzed the patient safety risks for Harvard-affiliated institutions by interviewing clinicians and convening system leaders both locally and nationally. System expansions create 3 types of significant safety risks, often unrecognized and unaddressed,thatarerelatedtochangesinpatientpopulations, infrastructure, or clinician practice settings (Table).

Mark E. Reynolds

Papers

The Risks to Patient Safety From Health System Expansions.