Since 1951, the U.S. Army-Baylor University Graduate Program in Health Care Administration (HCA) has been preparing graduate students to assume leadership positions with federal healthcare organizations. The historical evolution of the U.S. Army-Baylor University HCA program has been described (Neuhauser 1983; Krieger and Leahy 1988; Neuhauser and Neuhauser 1995; Ginn 1997; Wainright, Rogers, Finstuen, and Mangelsdorff 2001; Mangelsdorff, Pryor, and Finstuen; Richards). Several recent developments have shaped the modern Baylor HCA curricula: the joint medical executive skills competencies (Deputy Secretary of Defense 1991; Joint Medical Executive Skills 2001) and evidenced-based health administration educational outcomes (Griffith 2000; Davidson, Andersen, Hilberman, and Nakazono, 2000; Wan, 2000).
What elements of academic courses and job assignments should be incorporated into the professional development of military treatment facility (MTF) commanders and leaders? In the Defense Appropriations Act of 1992, Congress mandated that MTF commanders be required to demonstrate “professional administrative skills” (Deputy Secretary of Defense 1991). The Secretary of Defense for Health Affairs convened a Tri-Service Task Force in early 1992 to identify executive competencies required of leaders to successfully command MTFs (Joint Medical Executive Skills 2001). The various competencies (knowledge, skills, and abilities) identified in the joint medical executive skills development program are accepted in both private and military sectors (Hudak, Brooke, and Finstuen, 2000). The set of competencies identifies basic skills that a potential MTF commander should possess before assuming command. The Surgeons General of the Army, Navy, and Air Force have approved the methods by which HCA competencies may be acquired. The only academic curriculum addressing all the required Department of Defense (DoD) competencies is the U.S. Army-Baylor University HCA program.
Evidence-based methodologies are based on data, measurement, and outcomes (Griffith 2000; Davidson, Andersen, Hilberman, and Nakazono 2000; Wan 2000). Concern with evidenced-based health administration educational outcomes came to the forefront with the Association of University Programs in Healthcare Administration (AUPHA) task forces starting in 1998, seeking to develop defined measures of educational outcomes. Griffith (2000) states: “it intends a systematic, outcomes-oriented, evaluation and improvement of the educational process.” Davidson and associates (2000, 2002) suggest a framework for evaluating the impact of health services management education. The elements include: environmental inputs, structure, process, outcomes, and recommendations. The long-term impact educational outcomes should be reflected in both the Individual (career advancement, increase in status) and the Society (high performing organizations, healthier populations, satisfied consumers).
The U.S. Army-Baylor University HCA program provides a unique opportunity to assess the impact of an educational program on the Military Health System (MHS). Since the majority of the graduate students are military officers who serve in military healthcare facilities, tracking their career progression allows assessing the value added of the U.S. Army-Baylor University HCA experience in a variety of military settings in the MHS. The context of organization outcomes includes all the Army MTFs where U.S. Army-Baylor University HCA graduates execute their leadership skills. During the time from 1994 to 2001, all of the Army MTFs in the MHS (n=38) were examined by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). In a similar but shorter time frame (1997-2001), DoD patient satisfaction assessments were conducted. The purpose of this research is to assess the impact of an educational program on the Military Health System on some of the evidence-based educational outcomes for the Individual (student) and the Society (all Army MTFs).
Society (Army MTF) Outcome measures include: JCAHO outcome scores and monthly patient satisfaction scores. JCAHO scores for all of the 38 Army MTFs during the period 1994 to 2001 were examined as a function of the DCA’s role (whether a Baylor graduate or not). Some MTFs were inspected up to three times. All the Army DCAs had earned master’s degrees, so educational levels were considered comparable. The analysis considered the independent variables of: year of survey, size of MTF (Clinic, Medical activity, or Medical Center), DCA (whether Baylor graduate or not), and covariates: time on station of DCA (months), and years of military experience of DCA at time of JCAHO inspection. There were no significant effects for the two covariates (time on station or years of military experience). The General Linear Model analysis shows Army MTFs with DCAs who were Baylor graduates had significantly higher JCAHO scores: F (1,97) =28.30, p<.001. There were significant interaction effects for year x size of MTF (p<.001), DCA x size of MTF (p = .048), and year x DCA x size of MTF (p<.001). The findings were most noticeable in the Medical Centers, with Medical Centers having Baylor DCAs receiving higher JCAHO scores. The model accounted for R2=.652 (Mangelsdorff, Mulkey, Rogers, Finstuen, Ruiz, Pryor, and Dominguez 2002). See Table 8 for details on the JCAHO scores.
Frequently JCAHO scores in DoD MTFs exceed those in civilian health care facilities (Sears 2000). For 1999, the overall grid scores for inpatient DoD facilities were 92.3 compared to civilian facility results of 90.7. Two Army MTFs received perfect 100 scores on their JCAHO inspections in 1998 and in 1999. Of the 4,900 inpatient facilities reviewed nationwide by JCAHO in 1999, less than 1 percent received 100 scores from JCAHO. Similar greater JCAHO scores were obtained in ambulatory DoD facilities than in civilian ambulatory clinics.
Individual patient satisfaction surveys from Army MTFs were examined on the monthly consumer satisfaction survey scores (Military Health System Surveys 2001; Mangelsdorff and Finstuen 2003) from January 1997 to September 2001 as a function of the DCA (whether a Baylor graduate) in command. The analysis considered size of MTF (Clinic, Medical activity, or Medical Center) and DCA (whether Baylor graduate) for several dependent measures. The dependent measures were: q3j “Overall quality of care and service received,” q4 “Recommend provider to family or friends, q5 “How satisfied with medical care received at clinic,” and q12 “Satisfied with clinic during this visit.” The General Linear Model multivariate analysis findings for DCA showed significant main effects for size of MTF on all four dependent variables (p<.001) with Medical Centers rated highest satisfaction and for DCA for q5 (p = .021), with Baylor DCAs having higher satisfaction scores. Additional significant interaction effects emerged for all four dependent variables (p<.001), with the effects most noticeable in Medical Centers under Baylor graduates having highest satisfaction scores.
For the Society (Army MTF) Outcomes, the JCAHO scores at the Army MTFs were informative. Military medical treatment facilities meet, and often exceed, civilian benchmarks. Army MTFs with Baylor DCAs had significantly higher JCAHO scores than non-Baylor DCAs during the period 1994 to 2001. Patient satisfaction scores also exhibited higher levels in MTFs with Baylor graduate DCAs particularly in Medical Centers, though the effects appeared somewhat attenuated, perhaps due to the shorter time frame used.
The superior performance of the MTFs with Baylor DCAs may be a function of the large number of Baylor graduates in Army MTFs in senior positions mentoring and guiding the career progression of recent Baylor graduates. Baylor graduates network very effectively at professional meetings and use technology to effectively communicate and exchange professional and personal information. A recent formalization of the networking process has evolved with the DCA Community of Practice (Baylor DCA Community of Practice web page). This becomes a powerful resource for current HCA students and residents to observe how the senior leaders work and address problems. Involving students and residents in the Community of Practice exposes them to an expanded network of executives, faculty, and resources to help make decisions. Access to knowledge and best practices leveraged by technologies are the objectives.
One measure of a program's effect is the impact on other educational programs. Baylor program directors, faculty, and graduates have gone on to establish other successful programs at institutions including: George Washington University, Trinity University, University of Houston Clear Lake, Arizona State University, Quinniapiac College, Virginia Commonwealth University, Robert Morris University, Our Lady of the Lake, Pittsburg State University, Southwest Texas State University, Nova Southeastern University, University of the Incarnate Word, Central Michigan University, and Western Kentucky University. Senior leadership positions in ACHE, AUPHA, AAMA, AMA, and APA have been notable.
A final statement about the program emphasizes internal and external assessments. Continued internal program assessments (curriculum reviews) and external reviews (Accrediting Commission on Education for Health Services Administration program accreditations of 5 years in 1987, 8 years in 1993, and 7 years in 2001; 6 ACHE student chapter awards) attest to the strengths of the U.S. Army-Baylor University HCA program.
The MHS actively promotes the improvement of the health of its beneficiaries through wellness, prevention, and population health programs. Educating the shareholders (patients, beneficiaries, professional and support staff, senior leaders) and leveraging technology to share best practices for the administrators will help improve the quality patient care of the MHS and other health systems.
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