Transforming the Culture of a Large Academic Medical Center: Where We’ve Been, Where We Are, Where We’re Going

ABSTRACT

TITLE: Transforming the Culture of a Large Academic Medical Center: Where We’ve Been, Where We Are, Where We’re Going

BACKGROUND: In 1999, after 8 years of planning, Indiana University School of Medicine (IUSM) adopted a competency curriculum for undergraduate medical students. The 9 competencies in the curriculum are: Effective Communication; Basic Clinical Skills; Using Science to Guide Medical Decisions; Lifelong Learning; Self-Awareness, Social & Community Contexts of Health Care; Moral Reasoning and Ethical Judgment; Problem Solving; Professionalism & Role Recognition. Despite this ground-breaking step, the school faced several ongoing challenges: a large, complex, intensely bureaucratic organizational structure, students’ dissatisfaction with their educational experience, significant gaps between the hidden curriculum and the formal competency curriculum, and a lack of faculty development to implement the new curriculum.

OBJECTIVE: In 2003 the Relationship-Centered Care Initiative (RCCI) was launched with the goal of changing the culture of the medical school to better align the hidden and formal curricula.

METHODS: With the help of two external facilitators, the RCCI used principles of emergent design and appreciative inquiry to guide the change process. Over the course of 5 years 175 faculty and students initiated more than 30 change projects: including admissions, faculty development, coaching for senior administrators and developing new faculty hiring practices.

RESULTS: Significant cultural change has occurred as evidenced by AAMC exit questionnaire data, faculty vitality surveys, and student narratives.

CONCLUSIONS: Large scale cultural change is possible using emergent design, an appreciative approach and belief in the positive potential for change. Such change depends upon creating opportunities for individuals at all levels of the organization to create and sustain change over time.

NEXT STEPS: Many senior leaders have already, or will retire soon. RCCI principles in operation to ensure a smooth transition include: mindfulness about succession planning, and continued evolution of appreciative practices that facilitate the change process.

BACKGROUND

•The usual (budget, space) plus•Anomie•Student/faculty/administrative rifts •Good USMLE scores, well above national average, but

• persistent student dissatisfaction with educational experience (never above the national average)• declining applications for the past decade

D. Craig Brater M.D., Ph.D., 1 Richard M. Frankel Ph.D., 1 Penelope M. Williamson, Sc.D. 2

1Indiana University School of Medicine; 2 Relationship Centered Health Care

OBJECTIVES

• To foster widespread reflection on and mindfulness of the values conveyed in everyday personal interactions and organizational behavior.

• To maintain an informal curriculum that consistently reinforces and exemplifies the values and principles of the competency-based formal curriculum in the domains of professionalism, communication, ethics and self-awareness.

• Use principles of emergent design to initiate self-sustaining culture change.

METHODS

First Steps: Create A Discovery Team and Conduct Appreciative InterviewsTwelve Interested Faculty Conducted 80 Discovery Interviews –

Main themes: Believing in the capacity of all people to learn and grow The importance of connectedness The importance of passion The wonderment of medicine

RESULTS

CONCLUSIONS

• Fruitful, inspiring work from the top down and bottom up

• Use of Appreciative Inquiry is an organizational attractor; active participation went from 12 to 175 faculty

• Use of Emergent Design can result in cascading, sustainable culture change activities

• Focusing on meaning and values creates a space for community, generosity and love to thrive

• May enhance the organizational environment for students, faculty, staff, and patients

• May help pave the way for organizational change

RESULTS

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For additional information please contact:Richard M. Frankel Ph.D.Regenstrief InstituteIndiana University School of MedicineE-mail address Rfrankel@IUPUI.Edu

Discovery Interview With an IUSM Faculty Member “I had a patient who had cancer and eventually lost both kidneys, got on dialysis, and had a stroke. An Indiana farmer, he had been an extremely independent man who was now very dependent ... He was miserable. Then he had a heart attack and was placed in the ICU. Once out, he said he never wanted to return…and didn’t want any more therapy. I had a junior student, Chris, who got very close to this patient. While I was out of town the patient died. Chris took it hard. He had worked with the patient and his family, mainly his daughter, to help them understand their options... I called the daughter, thinking she might be upset that I was out of town when her father died, but she was fine. A very religious woman, she told me that her family had wondered a long time why God had allowed her dad to suffer so much and for so long, but now she knew why. She said her dad went through all that and died to make Chris a better doctor.”

Next Steps: Town Hall Meeting, Appreciative Story Telling and

Use of Emergent Design to Identify Change Projects Sample Projects

Admissions•Increased diversity of committee members•Use of mock patients to improve interview quality•Student initiated admissions ambassador program

Courage to Lead Series•Consists of 4 day and a half long retreats•Attended by senior leaders, faculty and staff•Four cohorts (n=20 each) to date •Latest cohort with an interprofessonal focus

New faculty selection•Faculty recruitment based on matching science and culture together