During the last decade, VUMC thrived in an environment of increasingly rapid change. We have identified eight key external pressures that shape our vision for the future. These pressures are inter-related, and they simultaneously present challenges and provide opportunities. They will inspire and constrain our strategic evolution and the processes we use to accomplish our missions:

1. The condition of our national and international economy and the impact of rising health care costs on our economy are driving changes in funding and organization for patient care, research, and education.

2. Changing demographics, lifestyles, and socio-economic factors affect our patient, student, and faculty/staff populations.

3. Pressures to collaborate and manage across a wide variety of settings, e.g., through managed care, telemedicine, inter-disciplinary and inter-institutional research, out-sourcing, information sharing, and educational consortia, are increasing in concert with the evolution of new organizational structures and technologies which enable collaboration and management across settings.

4. Similarly, we are experiencing increasing pressures to monitor, measure, evaluate, and change based on data as new technologies and processes enable us to respond to these requirements.

5. Continuous advances in information and communications technologies require continual learning and adaptation. They require dynamic reassessment of our processes and create competitive pressures to meet standards and expectations for information management.

6. Increasing emphasis on prevention and primary care and focus on the patient's role in managing his/her health, disease, and recovery will affect practice, education, and research priorities.

7. The changing environment will require continual revision of our educational programs in order to assist a wide variety of learners in their adaptation to these changes.

8. The continuing explosion of health science knowledge, technologies, and capabilities challenges our ability to access and use information and changes the economics of health care.

1. VUMC must adapt to a managed care environment. We must be able to:
   1. Reduce cost, manage cost, and document efficiencies; explain what we do and why; by provider, employer, diagnosis, insurer, etc.

   2. Achieve and document quality outcomes. This requires using data differently and making it accessible so it can be used.

   3. Vary the care delivery mechanism when appropriate, by mixing care settings and provider types.

   4. Manage a variety of product lines: populations, clinical programs, and individual events of service.
      

   5. Be patient-, physician-, referrer-, and reimburser-friendly.

2. The historical pattern and source of funding for the Schools of Medicine and Nursing is changing and we must manage these changes. Key factors are:
   1. Reductions in clinical support from the hospital.

   2. Slowing growth of direct federal research dollars and decrease in indirect reimbursement.

   3. Conflict between increasing student debt load and expected ability to repay debt.

   4. Changes in student demographics.

3. Access to and management of information are expected and are standards for accreditation.

4. We must teach people how to operate in a world of accelerating change. VUMC must support life-long learning for faculty, staff, students, and patients, quickly incorporate curricular changes, and provide periodic opportunities for faculty and staff to alter career direction.

5. The power of, and necessity for, collaborative research projects will increase. Individual contributions that result in new shared resources, or resources that support collaboration, must be recognized and rewarded. Metrics must be identified to permit recognition of an individual's unique contribution to a collaborative project.