Evolving Student Social Entrepreneurship in a College of Medicine and Academic Medical Center: The B.R.I.D.G.E. Clinic at the University of South Florida Jack Burns, BS Ronit Zadikany, BS Jason Patel, BS Lucy Guerra, MD Eduardo Gonzalez, MD William G. Marshall, Jr., MD, MBA

Morsani College of Medicine, College of Business, and Center for Entrepreneurship University of South Florida – Tampa Tampa, Florida, USA

Summary The BRIDGE Healthcare Clinic at the University of South Florida Morsani College of Medicine is a student-developed and student-managed social entrepreneurial venture that delivers high quality healthcare to underserved adult populations in Hillsborough County, Florida. This project has succeeded on multiple levels with the development of an interprofessional (medicine, pharmacy, physical therapy, nursing, public health, social work) student organization for the delivery of clinical healthcare to an underserved community, provision of opportunities for clinical, entrepreneurship, and business education for the students, and the opportunity for students to manage, at all levels and in all aspects, a functioning healthcare organization. The students have successfully navigated all the typical issues of a social venture: resource constraints, the on-going need to raise new resources, recruitment and management of volunteer personnel, and engagement of philanthropic donors. The BRIDGE Clinic has demonstrated successful and sustainable inter-professional healthcare delivery and educational excellence. Keywords: Social Entrepreneurship, Healthcare Delivery, Organizational Sustainability, Inter-Professional Education Corresponding Author: William G. Marshall, Jr., MD, MBA 813-974-7663 [email protected]

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PRINCIPAL TOPIC In 2007, four medical students founded the B.R.I.D.G.E. Clinic (B.R.I.D.G.E. stands for “Building Relationships and Initiatives Dedicated to Gaining Equality”) at the University of South Florida Morsani College of Medicine (USF MCOM)1. Being creative, innovative social entrepreneurs (although as medical students, probably not recognizing it at the time), these four individuals envisioned that the BRIDGE Clinic would provide healthcare for an underserved population in the Tampa Bay area near USF2. From its inception, the BRIDGE Clinic achieved its goal of providing high-quality medical care without charge to patients, and now has served over 500 adult patients in its five years of existence. However, the success of the BRIDGE Clinic, like many social ventures and non-profit organizations, has not come easily. This paper will present and discuss how the BRIDGE Clinic, a student-developed and student-managed social entrepreneurial venture, focused on delivery of healthcare services and educational opportunities, has faced and managed the challenges of an evolving start-up social venture, while maintaining and delivering the original social vision of its founders.

METHODS The study of this case example was developed through interviews and data collection from the BRIDGE Clinic students and faculty and discussions with the students of the Business of Medicine Bootcamp at the USF MCOM. This study was developed to analyze the critical success factors necessary for the development of a sustainable and successful social venture conceived and managed by a group of healthcare students and the comparison of this example to other similar situations. Further, identification and analysis of those factors affecting the short- and intermediate-term results of the venture, both positively and negatively, have assisted our group in appropriate strategic and operational planning and will assist other groups who seek to develop this type of organization.

RESULTS AND IMPLICATIONS Background of the B.R.I.D.G.E. Healthcare Clinic There are thousands of individuals, “effectively” with too few financial resources or whose financial situation places them below the federal poverty level, simply unable to be seen regularly by a physician. The BRIDGE Healthcare Clinic was founded in 2007 by a 2

group of four senior medical students at the USF MCOM with the principle mission of working towards providing a local solution to this problem of appropriate access to healthcare for the underserved, while also providing students the opportunity to gain “experiential learning” in clinical care.1 The main goal of the BRIDGE Clinic has been to serve the underprivileged population of a portion of the Tampa Bay community (Zip Codes 33612 and 33613) by providing free healthcare services to individuals who could not otherwise afford healthcare. The BRIDGE Clinic was conceived as an organization that would provide healthcare services through students’ service under the guidance and mentorship of faculty. However, the responsibility of development and management would remain with the students and not controlled by the faculty or administration. While there are many student clinics across the United States, the BRIDGE Clinic is one of very few fully student-managed and studentgoverned clinics. Additionally, the BRIDGE Clinic has unique educational, training, and practice methods to train medical students (and other healthcare professional students) in clinical medicine and care as well as the business of healthcare3. In essence, the BRIDGE Clinic serves as a “learning laboratory” for students to not only to practice and develop clinical skills, but also to begin to learn and develop the skills needed to manage healthcare organizations and to start and manage a social entrepreneurial venture. With growth and expansion, other professional students have been made a part of the BRIDGE Clinic to expand the services provided and the educational opportunities. The BRIDGE Clinic first opened its doors at a local county health facility, with the space donated free-of-charge by the Health Department of Hillsborough County. The facility consisted of six exam rooms with the use of paper charts by the staff to maintain the health records of the patients. This proved to be adequate for the clinic in 2007, where it had a patient population of about 40, but would rapidly become a challenge due to a number of factors outlined below. The BRIDGE Clinic operated once a week to provide medical services to adults who earn below 200% of the federal poverty line and do not have healthcare insurance. All services and functions have been provided by students under the guidance of faculty mentors. The services and functions are inter-professional in nature including students from the professions of medicine, public health, pharmacy, physical therapy, nursing, and social work.

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The BRIDGE Clinic not only started growing in the number of patients seen and treated, but also in the services it provided. Soon after its establishment, the BRIDGE Clinic became a site for physical therapy and social work students to volunteer and practice their skills. The BRIDGE Clinic quickly transformed into a multi-disciplinary healthcare organization, and soon the students of the College of Medicine, College of Public Health, School of Physical Therapy, and School of Social Work were seeing patients at the BRIDGE Clinic. In 2011, the College of Nursing and College of Pharmacy expressed interest in joining the organization. As the number of patients started to rapidly increase each year, and with the expansion of services and professions providing the services also increased, the clinic struggled in trying to operate in a facility too small for the number of patients and faculty and staff required to care for them. Operationally, this proved to be a challenge, as many patients are under the care of more than one provider, and an efficient clinic flow had to be maintained to make sure each patient could be seen in a timely and effective manner. Additionally, the management structure of the clinic had to be reassessed, as each involved group of students at the BRIDGE Clinic had needs and concerns to maximize their educational experience and role within the organization. The student directors of the BRIDGE Clinic (all medical students since the organization was founded by medical students) have upheld the values and fulfilled the goals set forth by the founders, but, in the effort to advance and grow the organization, they identified areas where the BRIDGE Clinic could, and had to, improve. With the growth of the clinic, the directors saw that its sustainability needed to be addressed both organizationally and financially, formalized bylaws and a Board of Directors needed to be created, and the size and efficiency of the workplace needed to be assessed and optimized.

Direct Outcomes and Results The BRIDGE Clinic has demonstrated significant community and social impact, which continues to increase during the time of its existence. Metrics for the 2009 – 2010 and 2010 – 2011 academic years are shown below: 

1,000+ patients served (since October 2007)

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Total number of patient visits (2009 – 2010): 467

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Total value of services provided by billings (2009 – 2010): $265,000 4

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Total number of patient visits (2010 – 2011): 525

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Total value of services provided by billings (2010 – 2011): $305,000

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Total volunteer hours faculty, students, staff (2009 – 2010): 4,700

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Medical student volunteers (2009 – 2010): 100+

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Volunteer attending faculty physicians (2009 – 2010): 8

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Volunteer physical therapy attendings (2009 – 2010): 6

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Volunteer social work students (2009 – 2010): 6

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Volunteer social work faculty (2009 – 2010): 3

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Volunteer public health students (2009 – 2010): 3

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Volunteer public health faculty (2009 – 2010): 3

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Employed ARNP (2009 – 2010): 1

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Value of medical faculty salary [hours donated: 4 hours per week x 2 providers (Internal Medicine & Family Medicine) x 4 weeks per month x 12 months = 384 hours donated x $80.00 per hour]: $31,000 annually

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Value of faculty administrative time donated (200 hours per year x $80.00 per hour): $16,000

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Value of physical therapy, social work, and public health faculty salary: $50,000 annually

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Total direct value provided by the BRIDGE Clinic to the Tampa Bay community (2009 – 2011): $770,000

The Challenges of a Social Entrepreneurial Start-Up – The BRIDGE Clinic Limited resources and the struggle to achieve sustainability are common realities that afflict many non-profit and social entrepreneurship organizations, such as the BRIDGE Clinic, especially in the current economic climate. Serving as a free healthcare clinic, the BRIDGE Clinic embodies the characteristics of a social and community entrepreneurial venture where the entrepreneur(s) is/are organizationally and fiscally constrained and have to marshal and manage the existent resources for the venture, while concomitantly always seeking more resources. This was especially true for the BRIDGE Clinic since it had functioned for four years with student leadership that had changed every year and leadership that had minimal, if any, operational and financial business experience. With the continued growth in the number and needs of the patients and the increasing numbers and types of students, the organization was under 5

significant stress from many factors. Typical mechanisms used by social entrepreneurs to reach needed resources to offset the organizational and financial stressors include collaborations and partnerships. In order to achieve their stated goals for improvement, in 2011 the BRIDGE Clinic leadership sought the collaboration of the Business of Medicine Bootcamp (BOMB) of the Innovation, Entrepreneurship, and Business Scholarly Concentration in the College of Medicine. This is a classic example of the leaders of the social venture leveraging resources outside itself to add value to the organization at the lowest possible cost and seeking to concomitantly provide added value to the partner to further embed the partner in the relationship. The USF MCOM Business Scholarly Concentration was created in 2006 to allow medical students to explore their interests in innovation, entrepreneurship, and business while continuing their medical curriculum. The program teaches entrepreneurial and business skills and expertise through didactic, case-based, and experiential models, as a co-curricular program within the MCOM. The Scholarly Concentration included a unique program within a medical school known as the Business of Medicine Bootcamp4. The engagement with the BRIDGE Clinic provided an opportunity and mechanism for the Bootcamp graduates, through the experiential learning opportunity with the BRIDGE Clinic to apply, practice, and refine their newly gained skills and expertise5. The students of the Business Scholarly Concentration who participated in the Business of Medicine Bootcamp (BOMB) used entrepreneurial and business principles to provide creative and innovative solutions for the challenges faced by the BRIDGE Clinic. This provided significant benefit and value-added for both organizations so that all of the students of the BRIDGE Clinic and the Bootcamp could learn and benefit. A Business Plan for BRIDGE The Business Scholarly Concentration worked with the BRIDGE Clinic directors to develop a formal business plan, something the clinic never had, to address the identified challenges, to enhance the sustainability of the organization, and to create strategic and operational plans for the BRIDGE Clinic to achieve objectives and goals of the organization to successfully continue its mission. Governance

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A critical need identified within the BRIDGE Clinic was an improved and formalized governance structure. With the additional Colleges and Schools involved, a transition to a formal Board of Directors (BOD) was recommended to improve the inter-professional collaboration and provide all Colleges and Schools within the BRIDGE Clinic input into organizational decision-making. Operations By the beginning of 2011, the directors of the BRIDGE Clinic had determined that the facility at the county health department was too small to host the ever-growing clinic and worked with USF Health to secure a new clinic site at the Morsani Center for Advanced Healthcare on the USF campus. The students of BOMB devoted critical parts of the Operations Plan to assist and guide the move of the clinic. Issues addressed by the Board of Directors included “bottlenecking”, minimizing patient wait times, and maximizing student-patient interactions. Since the clinic is multidisciplinary, a system so that several teams could see the patient in a reasonable amount of time had to be devised. Two of the major changes included expansion of clinic space from 6 to 14 rooms and the implementation of a new Electronic Health Record system (EHR). The EHR was also devised for use as a communication tool between the front desk in the waiting room and that part of the clinic where patients were being seen. Its implementation would succeed in reducing the amount of paperwork that the clinic accrued, as well as streamline each patient’s information into one electronic chart. Implementation of the EHR was completed in an incremental manner due to electronic security issues and the known tendency of implementation of an EHR to result in decreased productivity for a significant period of time. An industry partner supported the implementation through a $35,000 philanthropic grant, another example of leveraging resources to accomplish goals and objectives without “money out of pocket.” Marketing A marketing plan to increase faculty and student recruitment was developed to help the BRIDGE Clinic meet the growing demand for physician and student volunteers to serve a larger volume of patients. A brief presentation detailing the benefits of volunteering at the clinic and a video demonstrating the clinic were created to increase awareness and foster more interest in the clinic among physicians in the MCOM and the Tampa Bay community. The patient population was also targeted in the marketing plan through a presentation of the BRIDGE Clinic at various health fairs throughout Hillsborough County. 7

Finance Funds for the BRIDGE Clinic were spread across a host of USF Foundation accounts with many different regulations for each account. The finance plan included formal accounting and financial systems to consolidate and streamline the fiscal management of the organization. Revenues were analyzed to determine the sources and amounts that the clinic was spending each year and from where the money originated. The historical spending patterns of the clinic were analyzed to develop an operating budget template for current and future use as well as future projections. A full investment policy for the management of future endowments was developed. The overall goal was a more organized structure for better management, more enhanced transparency, and better organization of the assets to ensure the sustainability of the organization and to eliminate any compliance issues. Philanthropy Plan As a not-for-profit venture philanthropy was critical to develop sustainable funding for the BRIDGE Clinic in its current state, as well as in the future. Although efforts had been made in the past to raise funds for the clinic, and in excess of $100,000 had been raised over the course of the clinic’s four-year lifetime, there had not been a unified effort to recruit and retain donors. To maximize the credibility and transparency of the clinic in the eyes of donors, a multifaceted effort was undertaken to acquire, analyze, and organize information about the clinic’s operations into a format that would easily provide donors with a picture of the clinic accomplishments each year, utilization of funds, and the monetary value of donations made to the clinic both in the form of services rendered and financial contributions. A donor list and an annual listing of the total financial donations to the clinic were created to better understand the profile of the donors and quantify the funds raised annually. Implications The BRIDGE Clinic has been able to function as a non-profit entity due to the assistance of donations and support from the University of South Florida, healthcare organizations, and local physicians and businesses. This support has come in the form of direct financial support and services-in-kind such as facilities, equipment, personnel, imaging, and laboratory tests. The financial status had always been tenuous and has only gotten more difficult in the current economic climate. Apart from financial resources, the clinic depends on volunteers – faculty and students – in the various healthcare professions to provide services. Thus far, the student 8

support and enthusiasm for volunteering at the BRIDGE Clinic has been successful and sustained. However, the clinic has found it increasingly difficult to recruit physician volunteers each year. The students of the other healthcare professions are also easily recruited, and the faculty in the other healthcare professions are engaged in relatively larger numbers, because in other Colleges and Schools engagement at the BRIDGE Clinic is likely considered a more formal part of the faculty assignment than in the MCOM. Furthermore, as the clinic’s patient population has grown each year, meeting the patients’ needs for these physician volunteers has become more and more critical and the recruitment of additional physicians has taken on an even larger focus. Other critical resources often in short supply have been facility space (resolved with the relocation to the Morsani Center for Advanced Healthcare), equipment, and access to the newer technologies that have become necessary for state-of-the-art healthcare delivery such as electronic health records, access to advanced imaging services, access to tertiary level consultants, and surgical procedures for patients. All of these needs carry significant costs for care of the patients of the BRIDGE Clinic. The BRIDGE Clinic has undergone a considerable metamorphosis during its growth, but the deep-seated values and commitment from student and faculty volunteers has allowed the organization to provide health services in excess of $250,000 per year for the last two years to those most in need in the Tampa Bay area. Engagement of the Business of Medicine Bootcamp has formalized the business aspects of the BRIDGE Clinic and the joint efforts of these two entities have led to increased community awareness, a greater number of donors, and more value provided to the community each academic year. The business plan will provide structure and guidance to the BOD, the Directors, and the faculty mentors in the on-going management and evolution of the BRIDGE Clinic. In this situation of a series of leaders with minimal business and entrepreneurship experience, this is critical for success and sustainability. The creative solutions provided by the Bootcamp have allowed for more underserved individuals to receive high-quality healthcare and for additional educational opportunities for more students of all healthcare professions. The BRIDGE Clinic has stayed true to its mission: delivering community service, providing educational opportunities for students, and creating a collaborative environment between student health professionals (e.g., medicine, physical therapy, public health, social work, pharmacy, and nursing). Over the past five years, the BRIDGE Clinic has managed to grow the patient population of the clinic from 40 to over 500 patients with over 1000 patient 9

visits since its initiation. Such significant growth often leads to chaos and inefficiencies, yet the Business Scholarly Concentration, in the form of the Bootcamp, has used innovative applications of standard entrepreneurial and business principles to help maintain efficiency and effectiveness within the BRIDGE Clinic. In founding a social enterprise, there is a considerable amount of evolution that takes place due to a variety of factors. The maintenance of a collective goal from all parties involved is critically important to the success and sustainability of a social venture. It is suggested that social mission is the social entrepreneur’s key driver, and features commonly held by social entrepreneurs include applying imagination and vision, seeing opportunities, risk-taking, securing resources, and persistence; all typical entrepreneurial characteristics and seen in abundance within these medical students and the other healthcare professional students6. This has been especially true in the creation of the BRIDGE Clinic. While the administrative structure, clinic location, and number of patients served all differ from what the founders originally imagined, the BRIDGE Clinic has not strayed from its social mission of providing high-quality healthcare to an underserved population. “Cross-pollination” between sectors is desirable if sustained progress toward health for all is to be a reality according to Drayton, et.al, and this is precisely what has occurred at the BRIDGE Clinic, between the various healthcare disciplines and the business of healthcare students7. The partnership between the BRIDGE Clinic, the Business Scholarly Concentration, and the Bootcamp has resulted in tremendous synergy, and the relationship has demonstrated the power of social entrepreneurship focused on the delivery of healthcare to the needy in the community and the ability to train students in these entrepreneurial concepts. Furthermore, the BRIDGE Clinic provided the Business Scholarly Concentration with an opportunity to promote sustainability, generate innovative solutions, create efficient and effective organizational growth, and allow students an opportunity to build, re-engineer, and manage a start-up healthcare venture with maintenance of all governance, executive, management, and business functions as student-directed under faculty mentorship. While the benefits to each organization and the students are more than enough to warrant a continued partnership, perhaps the greatest beneficiary is the ever-growing community of patients that have received excellent healthcare from the BRIDGE Clinic, an organization that will assuredly become a model for student-run clinics across the United States and encourage other medical and healthcare student social entrepreneurs to serve their communities with the “entrepreneurial perspective” noted by Kuratko8. 10

The Future Plans for the future include further integration of the health professions within the structure of the BRIDGE Clinic with expectations that the evolution of the direction and management of the organization will continue to evolve, probably in ways that cannot be anticipated at this time. This will also begin to set the future relationships between the healthcare professions in actual clinical practice. Additional technology solutions to continually improve patient safety, quality, and satisfaction are being developed and implemented including a patient database for more complete collection of all data from the clinic interactions to enable easier research and analysis of outcomes of the clinic, clinical, operational, financial, and community-focused. Additional grants continue to be sought from healthcare funding agencies including health insurance payors and agencies supporting the evolution of the United States’ healthcare delivery system to target specific projects within the BRIDGE Clinic and the Bootcamp and assist with the costs of general operations. It is our hope and expectation that the skills, expertise, and experience developed at the BRIDGE Clinic will make our patients healthier and happier, make our students more astute clinicians, and focus them on the most efficient and effective delivery of healthcare for all members of society regardless of their socioeconomic position.

REFERENCES 1. USF Health. BRIDGE Healthcare Clinic. 1 April 2012 . 2. Disney K, Carraher SM, Phelps J. (2009). “Social entrepreneurship and sustainable innovations in medical service.” Proceedings of the Allied Academies Internet Conference, 11, 151-154. 3. Meah J, Smith E, Thomas D. (2009) "Student-run health clinic: novel arena to educate medical students on systems-based practice." Mount Sinai Journal of Medicine 76: 344-356. 4. Zadikany R, Patel J, Marshall WG Jr. (2012) "Teaching Medical Students Healthcare Entrepreneurship: The Business of Medicine Bootcamp - BRIDGE Clinic Collaboration at the USF College of Medicine." Proceedings of the United States Association for Small Business and Entrepreneurship (USASBE). 5. Reeves C, et al. (2011) "Healthcare Innovation and Entrepreneurship For Medical Students." Proceedings of the International Council for Small Business (ICSB). 6. Farmer J, Kilpatrick S. (2009) "Are rural health professionals also social entrepreneurs?" Social Science & Medicine 69: 1651-1658. 7. Drayton W, Brown C, Hillhouse K. (2006) "Integrating social entrepreneurs into the "health for all" formula." Bulletin of the World Health Organization 8.84: 591.

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8. Kuratko DF. “Entrepreneurship Education: Emerging Trends and Challenges for the 21st Century.” 2003 Coleman Foundation White Paper Series for the U.S. Association of Small Business & Entrepreneurship

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