The times they are a changin’

1. The times they are a changin’ Are you ready to handle (lead) change at your home institution?

2. Outline • Implications of change • The importance of understanding the difference between strategy and culture

3. With the introduction of the outcomes project, GME has begun the evolution to competency based education training. This is change!

4. Change is not always an improvement and is never easy!

5. “If you want to make enemies, try to change something.” Woodrow Wilson

6. Carraccio, et al. 2002.

7. Change in Transitioning to CBME

8. You can not lead a horse to water…. …..but you can put salt in it’s food!

9. Principles of Change Management • People react differently to change • Everyone has fundamental needs that should be addressed during change • Expectations need to be managed realistically • Fears need to be addressed • Change often involves loss, people can experience grief reactions

10. Case in point • Dr. X is a traditional master clinician/teacher. • He/she verbalizes support of your transition to competency-based training and learner-centered teaching. • Yet on rounds, he/she continues to teach to, and not with trainees utilizing a mini-lecture format. He/she also never does the direct observation you have asked be completed. • In theory, Dr. X supports you, but in practice is unwilling (or unable) to change. • What is going on?

11. Diffusion of Innovation

12. Fundamental Needs During Change Change Management • Control • Some degree of control over one’s environment or destiny • Inclusion • Some degree of involvement in the process • Openness • Some degree of understanding of intentions/information sharing from leadership

13. Know Your Constituency The Way We Talk Can Change the Way We Work • Kegan and Lahey • “Assumption as truth” • “Assumption as assumption” Theory U • Otto Scharmer • The process of change .

14. Assumption as Truth • Easily produced – Petrie’s “cognitive map” • Creates a sense of certainty, that one’s perspective is reality • Preservation of status quo (fear of change) • Non-transformational • Maintains the world as we have been constructing it • Immunity to change

15. Assumption as Assumption • Produced with difficulty – takes work! • Creates valuable doubt • Transformational • changes the world as we understand it to be, and our sense of our possibilities within it • Creates a means to disturb our immunity to change – changing our “cognitive map”

16. Theory U Change is hard work. It takes time! Otto Scharmer

17. The Reality of Change • you are kidding yourself if you think you can develop a change plan and then simply tell people to implement it. • People will resist aligning with something they do not believe in or understand • People can't just drop everything and 'change'. Even if they want to, they have a full plate keeping them busy most of their waking day.

18. The Pace of Change?

19. Elisabeth Kubler –Ross Grief Reaction • Denial – “Our fellows learn just fine. We don’t need to change.” • Anger – “Whose stupid idea is this anyway. The ACGME doesn’t know squat!” • Bargaining – “So maybe I can still lecture if I let the fellow’s pick the topics they want” • Depression – “I’m a dinosaur. Maybe I should just retire” • Acceptance – “So tell me again about this CBME.”

20. What challenges do you face as you address change in your institution?

21. Change, Strategy, and Culture

22. “Culture eats strategy for lunch every day” Do you know your fellowship and institutional culture? How do these cultures influence your strategies for implementing change?

23. Strategy • a plan of action designed to achieve a particular goal • Culture • the attitudes and behavior that are characteristic of a particular social group or organization • Hidden curriculum • the informal way in which cultural values are transmitted, through the structure of teaching and the organization

24. Darrell Kirch “ expressions of great concern or even deep disillusionment regarding our ability to advance our core academic mission.”

25. Darrell Kirch (continued) “the source of our discontent is a fundamental imbalance within our institutions – an imbalance that stems from a failure to put at least as much energy into improving/understanding our culture as we put into advancing our strategy.”

26. Do you know the culture and hidden curriculum of your fellowship?Your department?Your institution?Does it really matter?

27. Medical education does not take place in a cultural vacuum, within a value-neutral environment Messages transmitted via the hidden curriculum may be in direct conflict with what is being promoted as necessary and good change The system is not broken, why fix it? Education redesign is great, but not at the expense of institutional service needs GME is fine as long as it does not interfere with the real work of the institution

28. Generic MissionsHow big are your circles? Patient Care Research Education

29. How Big is Your Piece of the Pie? • Clinical Care • Research • Education • Advocate strongly for your piece! • Is your piece of the pie part of mainstream institutional culture?

30. How does your educational enterprise promote the research and clinical care missions? • Because the ACGME says so is just not enough! • GME outcomes in Patient Care that promote your institutional patient saftey priorities - not just meeting the ACGME general competency requirement? • GME involvement in section/department quality improvement initiatives?

31. Additional Resources • Getting to Yes – William Ury and Roger Fisher • Getting Past No – William Ury • The Harvard Business Review on- • Leadership • Mentorship • Change

32. Choose wisely!

33. Questions