A WORKSHOP

1. A WORKSHOP • The Change Process & Leadership in Medical Education in a Complex World • Stewart Mennin, PhD • smennin@gmail.com

2. TABLE OF CONTENTS

3. THE CHANGE PROCESS • Change is inevitable. It is a constant process. Education programs and curricula are life- • long processes--they grow and develop, age, repair themselves, learn and provide for their • continuance, like a living organism. How do we take the pulse of our changes? What • measures of health and success can we apply to our medical education program? How can • we guide and mold change so that it reflects what is needed in a way that is harmonious • with the whole of our institutions? • Four stages characterize the process of change: • 1. Awareness and recognition of the need for change • Interaction and exchange lead to an awareness and a recognition of the need for change. This awareness could come from outside or inside of the institution, it could occur in the mind of a single person or at the same time in a group. The process is not different from the way we seek to understand our research or our patients. Faculty, staff, and the educational leadership recognize the imperative to nourish individuals and provide a framework for the examination of and reflection on programs and curricula. The role of leadership is to make it permissible and desirable for others to not only recognize, but also act on this imperative. • 2. Development of a broad vision leading to a well-developed and specific plan • Visions are non-specific and tied to broad institutional and social needs. Their purpose is to bring people with diverse perspectives together around shared values, perceptions, and needs. • Formal leaders usually (but not always) articulate vision. • For the details of a vision to become a specific plan, they must be worked out and specified by broad-based groups of faculty and staff over a period of time. • The time required for building ownership and buy-in varies with each institution but is usually between two and five years. The length of time depends on the history, culture, and leadership of the institution.

4. Implement Revise Reflect & Evaluate THE CHANGE PROCESS (continued) • 3. Implementation • This can be a stressful time for the leaders of the change process. • Resources and time are identified. • Rewards and incentives to participate in the process are made explicit. • Ideas and methods are tested as part of the cycle of implementation--reflection and evaluation, revision, and implementation. • 4. Adoption (acceptance) or rejection of the change • Over time, faculty incorporate the change into the larger picture of the institution. This occurs when the change is viewed as valuable, profitable, and consistent with social/cultural norms. The challenge at this point is to sustain the change over time. • OR • The change fails to take hold and is rejected. Lessons learned from this are valuable.

5. MANAGING THE STAGES OF CHANGE A. List or describe one or more changes in medical education at your school that are needed. Or Assume your change, program, course, or curriculum has been implemented. List what you believe is needed to sustain and continue to improve educational programs over time. B. List the factors that stimulated an awareness of the need for the change(s).

6. MANAGING THE STAGES OF CHANGE (continued) • C. Barriers to Change • List the barriers that arose or were perceived with respect to the change at your school. • Next to each barrier, write the word or words that best characterize it--e.g., physical resources, people, time, money, attitudes, leadership, incentives and rewards, other. • D. Strategies for Change (Optional) • List key methods and strategies that facilitated the implementation of new programs or change at your institution.

7. ADAPTIVE WORK Most curriculum changes are complex events. To have sustainable positive outcomes, curriculum change needs to be approached from the perspective of adaptive leadership. 1. What is Adaptive Leadership and How Do You Apply it in medical education? Adaptive leadership is mobilizing people to do work that consists of the learning required to address conflicts in the values people hold, or to diminish the gap between the values people stand for and the reality they face. Adaptive work requires a change in values, beliefs or behavior. Three Key Elements: Context, Differences, Energy & Re-Organization Context Context consist of parameters, boundaries, environment, values, rules, beliefs, organızational norms, etc. Leadershıp helps to set the conditions and situation for adaptive work, advances goals, designs and strategies for learning that promote adaptive work. Contxts are the open to the outside world and interact with ıt. Differences Differences are a source of solutions. An adaptive leader takes action to help people clarify values, usually by bringing together diverse views and promoting learning. Re-Organization (Self-Organızation) An adaptive leader promotes high quality exchange as a means of learning for adaptive problem solving and maximizing the probability of self-organization

8. ADAPTIVE WORK Think of a curriculum change you have been or are planning to be involved with. Describe below the Context, Differences and Perspectives, and Self-organization that characterize it. Boundaries Adaptive Leadership Define your own specific strategies for adaptive leadership in your situation. Diverse Perspectives (Differences) Re-Organization

9. Expected Done Fulfilling expectations for answers Asking questions Protecting from outside threats Letting people feel the threat to stimulate action Orienting people to current roles Disorienting people, allowing new roles to emerge Quelling conflict Generating conflict Maintaining norms Challenging norms LEADERSHIP FOR A CHANGE Adaptive Leadership – Mobilizing people to tackle tough problems. [Based on Heiffetz, R.A. (1994).Leadership Without Easy Answers. Cambridge, MA: Belknap Press of Harvard University Press.] Adaptive work consists of the learning required to address conflicts in the values people hold, or to diminish the gap between the values people stand for and the reality they face. Because adaptive leadership requires learning, the tasks of leadership consist of choreographing and directing the learning process in the organization or group. Adaptive work requires a change in values, beliefs or behavior. Leadership with or without authority requires an educative strategy. Exercising leadership from a position of authority in adaptive situations means going against the grain. Going Against The Grain Leading with Authority Mobilizing adaptive work Authority as a resource for leadership Managing the holding environment Directing attention Gathering and influencing the flow of information Framing the terms of the debate Distributing responsibility Regulating conflict and distress Structuring the decision processLeading Without Authority Latitude for creative deviance Single issue focus Frontline information Modulating the provocation

10. ADAPTIVE LEADERSHIP • Leadership Skills • An effective leader uses strategies to mobilize adaptive work, as described for each of • the following. • Context • Setting goals that meet the needs of both leaders and followers • Allocating resources • Fan the flames • Setting time lines • Deciding who will play (identifying stake holders) • Managing the holding environment (sequence the issues) • Directing attention • Frame the terms of the debate • Distribute responsibility • Regulate conflict and distress • Structure the decision process • Managing sustained periods of stress • Counteract expected work avoidances and help people learn despite resistance • Differences • Inform reality testing • Identıfy or create positive deviants • Fire the forces of invention and change • Get people to clarify what matters most in what balance with what adaptations. • Clarify values in the context of problems demanding definition and action • Orchestrate conflicts among and within the interested parties • Re-Organization • Gather and influence the flow of information • Identıfy the next steps • Strengthen the bonds that join the stakeholders together as a community of interests so that they withstand the stress of problem-solving • Facilitate and deriving norms of responsibility taking, learning and innovation • Promote exchange of differences

11. YOUR PROGRAM CHANGES Describe program modifications and/or strategies you plan to address in order to take the next steps at your institution. What When Who How

12. SUMMARY CHANGE STRAGIES • Build broad-based ownership and buy-in. • Involve faculty and staff in detailing the generalized and agreed-upon broad vision. • Orient the vision and goals toward the health of the public. • Negotiate methods, not values. • Emphasize effective communication. • Communicate in a well-developed, iterative, thorough, and bi-directional manner. • Utilize multiple formats, media, and venues. • Centralize governance for medical education. • Provide governance with necessary resources for education. • Hold groups accountable for meeting goals. • Focus institutional values on needs of learners and society. • Develop leadership for education. • Identify formal and informal leaders. • Specify desirable knowledge, skills, and abilities for leaders. • Provide a means for facilitating the development of desired knowledge, skills, and abilities. • Re-examine and improve incentives and rewards for education. • Assure that incentives and rewards related to the change comprise a significant part of the faculty/staff promotion process.

13. SUMMARY (continued) • Make meaningful faculty development an ongoing process. • Facilitate agreement among faculty on standards for teaching. • Institute peer review and quality assurance, the results of which are discussed and implemented by faculty. • Orient new faculty and new students and train them in the institution’s educational philosophy and methodology. • Implement and sustain ongoing program evaluation. • Collect data and study what you do objectively. • Evaluate to improve, not to prove; ensure timely, short-loop feedback. • Innovate student assessment methods. • Ensure that assessment and the learning process are congruent and consistent. • Include students. • Include them in the process, planning, and evaluation. • Recognize that students are a renewable resource; they are energized and involved. • Include students in problem-solving--they will help you if you let them.

14. Never Opinion Leaders Late Adopters Early Adopters Innovators Everett Rogers, 2003 CHANGE & DIFFUSION OF INNOVATIONS

15. BARRIERS TO CHANGE • Fear of Loss of Control • Fragmentation • Status Quo • Do No Harm • Unsupportive/indifferent Leadership • Insufficient Energy of Activation • Failure To Achieve Critical Mass • Dissonant Values and Goals • Time, Money, Space • Dysfunctional Governance • Ineffective Faculty Development • Insufficient Know-How In Education

16. COMPLEX ADAPTIVE SYSTEMS • Key properties of complex adaptive systems • These interactions tend to be non-linear and feedback on one another; • Boundaries, both between the system and its environment, and between the internal compartments, are indistinct and dynamic; • Small changes can lead to large effects and large changes can have small effects; • As agents interact, they each change or co-evolve; • Energy and other resources are extracted from the environment and are continuously dissipated, keeping the system ‘far from equilibrium’. • There is a turnover of components, but structure and information are preserved over time; • The system can adapt to changes in the internal and external environment; • There is an overlap between subcategories of agent in the system, so that an individual agent may belong to more than one subcategory; • Because of this connectivity, fuzzy boundaries and overlap it is difficult to simply remove a part of the system and replace it; • The system has a history, which determines its current structure, internal organization and behavior, so that it is capable of learning; • Emergent properties may arise through the lower-level interactions between agents. • Such properties cannot be understood at the level of the agents themselves.

17. 7 6 5 4 3 2 1 STACY MATRIX The edge of chaos (zone of complexity) Far from Agreement Close to Agreement Close to Certainty Far from Certainty Brenda Zimmerman, Curt Lindberg, Paul Plsek Edgeware © 2001, Plexus Institute

18. STACY MATRIX MODIFICATION • Strategies based on Complex Adaptive Systems • Define the boundaries (container; open) • Bring individuals together (exchange of differences) • Facilitate and create conditions for self organization (emergent patterns from dynamic coupling) • Direct people to complete Tasks • Change work processes to facilitate self-organization • Modify structure to increase diversity, information and connections • Bring agents from different complex adaptive systems together to intervene and seek change • Bring agents from different complex adaptive systems together to facilitate self-organization • Examine and describe patterns that are beyond leaders’ influence • Scan the system for patterns

19. SUGGESTED READINGS ON CHANGE • SELECTED READINGS ON CHANGE • Bennis, W.G., Benne, K.D., Chin, R. The Planning of Change. (eds), 4th Edition, 1985. Holt, Rheinhart and Winston. NY, NY. • Berwick, D.M. 2003. Disseminating Innovation in Health Care. JAMA April 16, 2003, 289(15):1969-1975. • Bloom, S.W. 1988. Structure and ideology in medical education: an analysis of resistance to change. Journal of Health and Social Behavior, 29 (December): 294-306. • Bloom, S.W. 1989. The medical school as a social organization: the sources of resistance to change. Medical Education 23:228-241. • Bransford, J.D., Brown, A.L., Cocking, R.R. 2000. How People Learn: Brain, Mind, Experience, and School. National Academy Press, Washington, D.C. • Hall, G. and Hord, S. Change in Schools. , 1987. State University of New York Press, Albany, NY. • Heifetz, R.A. Leadership Without Easy Answers. 1994, Belknap Press, Harvard University Press, Cambridge, Mass. • Hesselbein, F., Cohen, P.M. Leader to Leader: 1999. Jossey-Bass Publishers, San Francisco, Calif. • Kaufman, A. 1998. Leadership and governance. Academic Medicine 73(9):S11-S15. • Levine, A. Why Innovation Fails. 1980. State University of New York Press. • Mennin, S.P., Krackov, S.K. 1998. Reflections on relevance, resistance, and reform in medical education. . Academic Medicine 73(9):S60-S64. • Mennin, S. P. & Kaufman, A. 1989. The change process and medical education. Medical Teacher 11 (1):9-16. • Mennin, S., & Kalishman, S. (Eds) 1998. Issues and Strategies for Reform in Medical Education: Lessons from Eight Medical Schools. Academic Medicine 73 (Supplement). • Moss Kanter, R. The Change Masters. , 1983. Touchstone, NY, NY • Rogers EM. 2003. The Diffusion of Innovations (5th Ed) The Free Press, New York • Peters, T., Thriving on Chaos. 1987. Knopf, NY, NY • Robins, L.S., White, C.B., Fantone, J.C. 2000. The difficulty of sustaining curricular reforms: A study of "drift" at one school. Academic Medicine 75:801-805. • Schwartz, P., Mennin, S.P and Webb, G. 2001. Problem-Based Learning: Case Studies, Experience and Practice. Kogan Page Press, London. • Wheatly, M.J. Leadership and the New Science. 1992. Berrett-Koehler Publishers, San Francisco.

20. SUGGESTED READINGS ON LEADERSHIP • SELECTED READINGS ON LEADERSHIP • Crum, T.F. (1987) The Management of Conflict: Turning a Life of Work into a Work of Art. Touchstone, New York, New York. • Fisher, R., Ertel, D. (1995) Getting Ready to Negotiate. Penguin Books, New York.Fisher, R., Ury, W., Patton, B. (1991). Getting to yes negotiating agreement without giving in (2nd ed). Penguin Books, New York, NY.Heifetz, R. A. (1994). Leadership without easy answers. The Belknap Press of Harvard University Press, Cambridge, MA.Mitroff, I. (1998) Smart Thinking for Crazy Times: The art of solving the right problems. Berrett-Koehler Publishers, Inc., San Francisco.Greenleaf, R.K., (1991) The Servant As Leader. The Robert K. Greenlear Center, Indianapolis, Indiana.Greenleaf, R. K. (1977). Servant Leadership a journey into the nature of legitimate power and greatness. Paulist Press, Mahwah, NJ.Jaworski, J. (1998). Synchronicity the inner path of leadership. Berrett-Koehler Publishers, Inc., San Francisco, CA.Neufeld, V., Khanna, S., Bramble, L., Simpson, J. (1995) Leadership for Change in the Education of Health Professionals. Network Publications. Maastricht, The Netherlands. • Wheatley, M. J. (1994). Leadership and the new science. Berrett-Koehler Publishers,Inc., San Francisco, CA.

21. SUGGESTED READINGS ON COMPLEXITY • SELECTED READINGS ON COMPLEXITY • Arrow H, McGrath JE, Berdahl JL. 2000. Small Groups as Complex Systems: Formation, Coordination, Development, and Adaptation. Sage Publications, Inc. Thousand Oaks, California • Barabasi A-L. 2002. Linked: The New Science of Networks. Perseus Publishing, Cambridge, Mass. • Capra F. 1982. The Turning Point: Society, and the rising culture. Bantam Books, S & Canada. • Capra F. 1996. The Web of Life: A New Understanding of Living Systems. Anchor Books. New York. • Capra F. 2002 The Hidden Connection: lntegrating the biological, cognitive, and social dimensions of life into a science of sustainability. Doubleday, New York. • Fraser SW, Greenhalgh T. 2001. Coping with complexity: educating for capability. BMJ: 323:799-803. • Glouberman S, Zimmerman B. 2002. Complicated and complex systems: What would successful reform of medicare look like? Discussion Paper, Commission on the Future of Health care in Canada. http://www.plexusinstitute.com/index2.cfm • Kauffman S.  1995. At Home in the Universe: The Search for Laws of Self-Organization and Complexity. Oxford University Press, New York, Oxford. • Lewin R. 1999. Complexity: Life at the Edge of Chaos. The University of Chicago Press. • McDaniel R, Driebe D. 2001. Complexity Science and Health Care Management, In: Advances in Health Care Management, vol 2:11-36. Elsevier Science Ltd. • Mennın S. 2006. Small-group problem-based learnıng as a complex adaptive system. (submıtted- Teachıng and Teachers) • Miller LM, McDaniel RR, Crabtree BF, Stange KC. 2001. Practicing Jazz: Understanding Variation in Family Practices Using Complexity Science. J Fam Pract 50(10):872-878. • Morin E. 2001. Seven Complex Lessons in Education for the Future. UNESCO Publishing. ISBN 92-3-103778-1 • Olson EE, Eoyang GH, Beckhard R, Vaill P. (2001) Facilitating Organization Change: Lessons From Complexity Science. Jossey-Bass, San Francisco, Calif. • Plsek PE, Greenhalgh T. 2001. The Challenge of complexity in health care. BMJ 323(15 September):625-628. • Rogers EM. 2003. The Diffusion of Innovations (5th Ed) The Free Press, New York. • Stengers I, Prigogine, I. (1997) The End of Certainty: Time, Chaos, and the New Laws of Nature. Free Press, NY, NY. •  Wheatley MJ. 1999. Bringing Schools Back to Life: Schools as Living Systems In: Creating Successful School Systems: Voices from the University, the Field, and the Community. Christopher-Gordon Publishers. http://www.margaretwheatley.com/writing.html

22. Workshop Evaluation • What will you do differently as a result of this workshop? Please be Specific • What more do need to learn? Please be Specific • The best part of this workshop was..... Please be Specific • Suggestions to improve this workshop. Please be Specific