Preparing Culture Change Agents for Academic Medicine in a Multi-Institutional Consortium: The C - Change Learning Action Network

Innovations

Preparing Culture Change Agents for Academic Medicinein a Multi-Institutional Consortium: The C - ChangeLearning Action Network

LINDA H. POLOLI, MBBS, MRCP; EDWARD KRUPAT, PHD; EUGENE R. SCHNELL, PHD; DAVID E. KERN, MD, MPH

Introduction: Research suggests an ongoing need for change in the culture of academic medicine. This articledescribes the structure, activities and evaluation of a culture change project: the C - Change Learning ActionNetwork (LAN) and its impact on participants. The LAN was developed to create the experience of a culture thatwould prepare participants to facilitate a culture in academic medicine that would be more collaborative, inclusive,relational, and that supports the humanity and vitality of faculty.

Methods: Purposefully diverse faculty, leaders, and deans from 5 US medical schools convened in 21/2-daymeetings biannually over 4 years. LAN meetings employed experiential, cognitive, and affective learning modes;innovative dialogue strategies; and reflective practice aimed at facilitating deep dialogue, relationship formation,collaboration, authenticity, and transformative learning to help members experience the desired culture. Robustaggregated qualitative and quantitative data collected from the 5 schools were used to inform and stimulateculture-change plans.

Results: Quantitative and qualitative evaluation methods were used. Participants indicated that a safe, supportive,inclusive, collaborative culture was established in LAN and highly valued. LAN members reported a deepenedunderstanding of organizational change, new and valued interpersonal connections, increased motivation andresilience, new skills and approaches, increased self-awareness and personal growth, emotional connection tothe issues of diversity and inclusion, and application of new learnings in their work.

Discussion: A carefully designed multi-institutional learning community can transform the way participants experi-ence and view institutional culture. It can motivate and prepare them to be change agents in their own institutions.

Key Words: culture change, academic medicine, medical schools, mumanistic, diversity, communities of practice,culture/diversity/cultural competence, evaluation-educational intervention, faculty development, grounded theory,reflective practice, leadership, professionalism/ethics

Disclosures: The authors gratefully acknowledge the critical funding sup-port of the Josiah Macy, Jr. Foundation, and Brandeis University Women’sStudies Research Center. Funding supported the design and conduct ofthe study, and collection, management, analysis, and interpretation of thedata. Supplemental funds to support data analysis were provided by the USHealth and Human Services Of!ce of Public Health and Science, Of!ceon Women’s Health, and Of!ce of Minority Health; National Institutes ofHealth, Of!ce of Research on Women’s Health; the Agency for HealthcareResearch and Quality; the Centers for Disease Control and Prevention andthe Health Resources and Services Administration.

Dr. Pololi: Senior scientist, Brandeis University; Director, National Initiativeon Gender, Culture and Leadership in Medicine: C - Change; Dr. Krupat:Director, Center for Evaluation, Harvard Medical School, Associate Pro-fessor of Psychology, Beth Israel Deaconess Medical Center; Dr. Schnell:President, Schnell Management Consulting; Dr. Kern: Emeritus Professorof Medicine, Johns Hopkins University School of Medicine.

Correspondence: Linda H. Pololi, Brandeis University, 415 South Street,Mailstop 079, Waltham, MA 02454-9110; e-mail: [email protected].

Introduction

Even with the altruistic motives of most medical faculty andthe noble missions of academic medicine, the present cul-ture in medical schools is felt by many faculty to be lonely,unwelcoming of differences, and more competitive and crit-ical than collaborative or supportive.1!8 Many faculty per-ceive discrepancies between stated mission and institutionalbehaviors.3,4,9 This culture contributes to high rates of fac-ulty dissatisfaction, burnout, and depression.10!13 In turn,dissatisfaction is associated with high levels of turnover andattrition.9,14!16 Also, there is a lack of diversity at all lev-els of leadership in medical schools.17!19 Despite calls forculture change in academic medicine to improve areas such

" 2013 The Alliance for Continuing Education in the Health Professions,the Society for Academic Continuing Medical Education, and the Councilon Continuing Medical Education, Association for Hospital Medical Educa-tion. • Published online in Wiley Online Library (wileyonlinelibrary.com).DOI: 10.1002/chp.21189

JOURNAL OF CONTINUING EDUCATION IN THE HEALTH PROFESSIONS, 33(4):244–257, 2013

Culture Change in Academic Medicine

FIGURE 1. C - Change Organizational Chart

as diversity and inclusion, interdisciplinary collaboration inresearch, civility, and so on,20!32 few interventions to facili-tate culture change in medical schools have been reported orevaluated.33 Furthermore, the accrediting body for US medi-cal schools has added a diversity standard,34 which will alsorequire culture change to accomplish.

The National Initiative on Gender, Culture and Leader-ship in Medicine, known as C - Change (for culture change),housed at Brandeis University, is dedicated to improvingthe culture of academic medicine through research andaction. Our objective is to promote an inclusive, human-istic, relational, and energizing workplace culture for allmedical school faculty and trainees, at the same time in-creasing the diversity of leadership in academic medicine(http://www.cchange.brandeis.edu). In contrast to most fac-ulty development efforts that are largely based on a skillsde!cit model,35!38 the C - Change Learning Action Network(LAN), was a change effort designed to create the experi-ence of a trustworthy, relational, collaborative, and humanis-tic culture for faculty, rather than equipping faculty to try tobe successful in existing cultures. We postulated that by edu-cating a small but in"uential and diverse group of faculty at 5medical schools about how culture impacts faculty potential,success, and diversity, and by having participants experiencethe desired culture, they would be impacted personally, de-velop skills, and bring about change in their medical schools.This article describes in detail the theoretical basis of the in-tervention, its process, participants’ views of the LAN andthe microculture that was created, and the impact participa-tion had on them personally. A separate article assesses theimpact LAN had at participant schools.39

Program Description

C - Change Organizational Structure

The Learning Action Network engaged 5 participating USmedical schools in a cross-school learning community from2006 to 2010. Data generated in earlier C - Change phases(the interview study,1!8,31 and the C - Change national fac-ulty survey,7,15,24 which documented the culture of academicmedicine) were used in the LAN to stimulate data-actioncycles that would facilitate culture change in participantschools40 (FIGURE 1).

School Selection and LAN Participants

Five schools were selected to represent different regionsof the United States, public and private, National Institutesof Health (NIH) research-intensive and community-orientedschools. The deans of these schools agreed to participate per-sonally in the LAN, and to have their faculty con!dentiallyinterviewed (Interview Study1!6,8) and surveyed (NationalFaculty Survey7,15,24).

With instructions about the need for diversity in LANmembership, the dean of each participating school submitteda list of potential faculty members, from which the LAN De-velopment Team selected 3 per school. We sought to achievemultiple goals in selecting the LAN members within andacross schools. The !rst was a desire that the LAN mem-bers represent the various demographic characteristics of thefaculty of their schools. We hoped that LAN members wouldbe interested and open to change and, importantly, that theywere diverse (within and between schools) on several key

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Pololi et al.

TABLE 1. Learning Action Network Participant Learning Objectives and LAN Process Goals

LAN Participant Learning Objectives

1. To expand the responsibility and ownership of achieving gender and racial equity in medical school faculty beyond dedicated equity personnel.

2. To deepen understanding of the factors necessary to promote faculty diversity, equitable advancement, and the achievement of all faculty members’ full

potential; to recognize these as factors reliant on the culture of their own institutions.

3. To enhance understanding of organizational culture change.

4. To emotionally connect with the struggles of women, minority, and other faculty seeking to !nd their voice and achieve their potential.

5. To enhance skills of change agency including listening, deep dialogue, collaboration, organizational change.

6. To apply these skills and learnings to the ways in which they relate to and support others, lead, mentor, and promote change in their daily work in and

beyond their home institutions.

7. To be stimulated by participation to initiate change in their respective institutions related to improving the culture of academic medicine.

LAN process goals

1. To assemble from 5 medical schools an effective learning community of faculty and leaders with the power and authority to drive change in their

respective institutions, together with some less powerful faculty.

2. To assemble in an effective learning community a group of faculty from 5 medical schools who are diverse in discipline, gender and race/ethnicity.

3. To create a LAN that models the culture desired for medical schools (i.e. one that is relational, supportive, collaborative, inclusive and diversity seeking,

safe, open, and humanistic).

4. To make objective and explicit in the LAN meetings the subjective experience of culture.

5. To use strategies (eg, re"ection) that facilitate learning in faculty.

6. To engage LAN participants both intellectually and emotionally in their experience of the culture.

7. To use objective data to make concrete the need for culture change.

LAN = Learning Action Network.

qualities: ethnicity, race, gender, seniority, and power (as de-!ned by holding administrative/decision-making roles). Weincluded senior and junior faculty and those with authorityto make change in their schools. Finally, we wanted to as-sure that they were drawn from different disciplines (basicscientists, generalist, and specialty physicians) and differentfaculty roles (clinicians, researchers/basic scientists).

The Learning Action Network

Leadership. C - Change and the LAN included several in-ternal structures to guide leadership and decision-making(FIGURE 1). A LAN Development Team (D.K., L.P., G.S.)consisted of an expert in organizational change and 2 aca-demic physicians with expertise in faculty development,medical education, physician-patient communication, diver-sity issues, and change in medical schools. It held biweeklyteleconferences and met for a day, quarterly, with other C -Change teams (Executive Planning, LAN Evaluation, Inter-view Study, and Faculty Survey) for planning, and to alignobjectives and timelines. The LAN Development Team de-signed the LAN intervention and its meeting agendas, and fa-cilitated activities at and between LAN meetings. This groupcoordinated with the LAN Evaluation Team (D.K., E.K.,

L.P.) with two overlapping members. A National AdvisoryGroup for the C - Change Initiative met annually. Its mem-bership included the !ve deans of the participating medi-cal schools together with national experts, for example, thepresident of the Association of American Medical Colleges(AAMC) and the president of a major teaching hospital.

Meeting Schedule. The inaugural meeting of the LAN in De-cember 2006 was followed by 7 biannual meetings, the lastof which occurred in September 2010. The 21/2-day meetingsrotated among the participating medical schools and Bran-deis University.

Design Principles. To address LAN objectives (TABLE 1),the LAN was designed to bring formal attention to AcademicMedical Center (AMC) culture and its many manifestationsin the daily life of faculty, staff, and students. We shifted theemphasis from goal-directed decision making to explorationof meaning and relationships in order to promote transforma-tive thinking. By designing LAN as a learning community41

that emphasized peer consultation and sharing of perspec-tives and expertise, LAN members took responsibility fordeveloping their own problem-solving approaches ratherthan relying on solutions that were imposed upon them.

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We employed 3 learning modes: experiential, cognitive, andre"ective/emotional.

LAN meetings were designed to embody characteristicsof the culture hypothesized to be needed in medical schoolsto support the humanity of the faculty and the overarchinggoals of the project. Speci!cally, we wanted LAN membersto experience the learning community as safe and supportive,one that (1) gave priority to relationships and high-qualitycommunication; (2) allowed members to express feelingswithout experiencing risk from speaking out, sharing prelim-inary thoughts, or pursuing dif!cult conversations42; and (3)was open to all points of view. Meeting facilitators were pur-poseful in modeling these behaviors through attentive listen-ing, positive regard and acceptance, empathy, and emotionalcongruence.43,44

The LAN Development Team used “emergent design”and re"ective process to plan LAN meetings. Rather thanplan the 4-year series of meetings in advance, each meetingwas designed based on what happened at the prior meetingand in between. This was important, as we were unable topredict events (eg, the transition in leadership at a medicalschool, or how LAN members would respond to activities inthe previous meeting).

Methods Used at Meetings

The following methods and areas of focus were included inthe meetings of the LAN.

1. Re!ective Practice. Each meeting incorporated time and meth-ods to “pause action” for group observation and discussionto promote self-awareness and mindfulness.45!47 Participantswere given time for re"ective writing. Visual images, metaphorsand poetry were used to deepen discourse and access insightsthrough intuitive thinking. Small groups of participants werechallenged with ambiguous and complex questions. Dedicatedtimes were allocated for “Walk and Talk” where dyads of LANmembers would walk outdoors and explore responses to ques-tions, such as: “What are you struggling most with in your homeinstitution?”

2. Appreciative Inquiry (AI). AI is a guided dialogue techniquebased on the concept that human systems grow toward what theypersistently ask questions about,48,49 with an emphasis on mov-ing attention away from de!ciencies toward exploring what in-dividuals and organizations are doing well. LAN members wereengaged in AI-formatted interviews and dialogue on speci!cquestion prompts, such as when they had experienced inclusiveenvironments or when they were able to bring their whole selfto work.

3. Knowledge Cafe. The LAN used a formalized group-basedknowledge acquisition process adapted from World Cafe(www.worldcafe.org).50 Known as Knowledge Cafe in the LAN,sequential small groups reviewed and discussed articles to en-courage “real-time” affective responses to learning that chal-lenged commonly held assumptions. Content areas included

leadership style, culture change conceptual frameworks, genderbias in assessment of leadership, nonconscious bias, and mind-fulness/re"ective practice.

4. Promising Practices. In order to ground LAN members in sto-ries of successful culture change, visiting experts were invited todiscuss their approaches and !ndings. These included presenta-tions from the University of Michigan ADVANCE program,51aNational Science Foundation (NSF)-funded project to promotewomen in science, technology, engineering, and mathemat-ics; the University of Wisconsin, on nonconscious bias andchanges in search committees52; and the Indiana UniversitySchool of Medicine,33 on aligning its informal/hidden and for-mal curricula.53,54

5. Work-in-Progress. Each school group presented works-in-progress at their respective schools for re"ection and discussionby the larger group.

6. Data-Action Cycles. To bring elements of workplace culture55,56

and its impact on faculty in academic medical centers into focus,we planned a series of data-action cycles. In early LAN meet-ings, quotations, derived from the Interview Study1!6,8 at theparticipating schools, were read aloud. In small rotating groups,each focusing on a theme in the qualitative data, LAN membersdiscussed the meaning of these data. Subsequently, all partici-pants engaged in discussion about (a) how the data personallyresonated with themselves individually, and (b) prioritizationof themes to address at their institutions. As quantitative sur-vey data became available from the combined 5 schools, partici-pants discussed the !ndings and their implications. We used theKnowledge Cafe (see above) process to facilitate discussion ofthe quantitative data. Deidenti!ed school-speci!c summary sur-vey data were also provided to each LAN school for review andresponse. Each school developed action plans based on the datapresented. These plans and resulting activities were presented atLAN meetings as work-in-progress sessions.

7. Focus on Organizational Change. Topics discussed at LANmeetings included traditional models of organizationalchange,57 fostering transformational change,58 facilitatingchange in complex organizations,59 and the role of changeagents.60 Given that organizational culture is not easily changed,LAN members were equipped to anticipate resistance, avoidpredictable distractions, and ready themselves for complicatedunfolding of events. Attention focused initially on identi!cationof key stakeholders and creation of broad-based engagement inC - Change schools. Later meetings focused on topics such ashow to sustain change during times of economic challenge andleadership transition.

Integrating Strategies. The following integrating mecha-nisms were created to facilitate integration between LANmeetings and across schools:

• LAN Liaisons. A LAN Liaisons’ group was formed to main-tain change momentum. It included 1 member from each school,who met monthly via teleconference. This group also providedfeedback for the planning of LAN meetings.

• Innovation Work Groups (IWGs). Four cross-school IWGsformed around themes identi!ed by LAN members through


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TABLE 2. Open-Ended Questions Used for Qualitative Data Analyses

Post-LAN Questionnaire

What important things have you learned in C - Change?

Please tell about the people you’ve met and the relationships you have developed during this project, and their importance to you.

When did you feel most alive and engaged in the LAN?

How would you describe what was most meaningful to you about C - Change to your best friend?

What prompted you to keep coming to the LAN meetings, even though you have a lot of important work to do?

Is there a way that this could have been a better experience for you?

A wish for the future?

Exit Interview

To what extent did you feel that the LAN was an effective change process?

In what ways did it assist the work?

In what ways do you think that the process could be improved?

Did your participation in the project:

Teach you about the ways in which change can be accomplished, especially at your school?

Make you more aware of challenges and obstacles?

Allow you to feel that you contributed to the professional development of others?

Assist in your own professional development?

Personal Impact Question (e-mailed approximately 1 year after the conclusion of LAN)

What personal impact, if any, has participation in C - Change had on you (ie, how have you yourself changed as a result of your participation,

in terms of knowledge, attitudes, skills, behaviors, or in any other way)? Please describe below or check None.

LAN = Learning Action Network.

discussion of the C - Change faculty interview data: CreatingHumanistic and Culturally Sensitive Environments; AligningPolicies and Rewards; Faculty Development and Mentoring;and Communication Between Faculty and Leadership. EachIWG had regular conference calls and presented their work atLAN meetings.

• Collegial Af"nity Groups. Two subgroups based on role simi-larity were formed. One, comprising the deans for multicultur-alism from three of the participating schools, held monthly tobimonthly teleconferences to discuss activities and provide mu-tual support. A second subgroup, consisting of the deans (chiefacademic of!cers) of each of the participating schools, partici-pated in a quarterly teleconference with the principal investiga-tor to discuss project progress.

Funding. C - Change received generous support from theMacy Foundation, with supplementary support from 5 fed-eral agencies. At the initiation of the project, we proposeda 5-year duration for the LAN, recognizing the slow pace ofculture change. A national economic downturn, coupled withchanges in funding foundation leadership and priorities, re-sulted in 4 instead of 5 years of funding.

All major costs of the meetings were assumed by theproject, including travel and accommodations, except for the

!nal meeting, which was partially supported by the partic-ipating medical schools. Neither LAN members nor surveyparticipants were compensated by C - Change. Macy Foun-dation funding supported the strategic development and op-eration of the C - Change Initiative, the 5-school faculty in-terview study, the C - Change National Faculty Survey, andthe development, implementation, administration, and eval-uation of the LAN. Funding limitations prevented provid-ing planned direct !nancial support for consortium schoolchange projects.

Program Evaluation

Data Sources

We used 3 data sources (TABLES 2 and 3) for the evaluationresults reported in this paper:

• Questionnaires completed anonymously after the last LANmeeting included Likert-style ratings as well as open-endedquestions (all 2010 members).

• Telephone exit interviews of all LAN members who actively en-gaged in at least 2 meetings, and all deans, obtained at LANconclusion or at their time of exit from the LAN.



TABLE 3. Participant Ratings of Learning Action Network (LAN) Elementsa,b

Overall LAN Evaluation Mean SD Range

Hearing about the problems and strategies at other schools 4.6 0.5 4–5

Informal time to get together with people from other schools 4.6 0.5 4–5

Speakers from outside the project (“Promising Practices”) 4.5 0.7 3–5

Attending LAN meetings 4.4 0.8 3–5

Having meetings emphasize and support relationship formation 4.4 0.8 4–5

Gaining new knowledge and skills for creating organizational change 4.3 0.8 2–5

Reinforcement of collaboration rather than competition 4.3 1.0 3–5

Large group discussion sessions 4.2 0.7 3–5

Working in small groups to discuss ideas at the LAN meeting 4.2 0.9 2–5

Using dialogue techniques/strategies, eg, Appreciative Inquiry and “Knowledge Cafe” 4.1 1.0 2–5

Receiving data about one’s own school from the C - Change Faculty Survey 4.1 0.9 2–5

Informal time to get together with people from my own school 4.0 1.0 3–5

Using literature and scholarship from the social sciences and management disciplines 3.9 0.7 3–5

Having time for myself for independent writing and self-re"ection 3.8 1.4 1–5

Hearing about the reports of the Innovation Work Groups 3.5 0.9 3–5

Involvement of school Deans 3.5 1.2 1–5

Having LAN Liaison structure 3.4 1.3 2–5

Participation in Innovation Work Groups 3.4 1.3 2–5

aRated from 1 (not at all valuable) to 5 (extremely valuable).bResponse rate = 74% and includes the responses of 14 of 19 LAN members.LAN = Learning Action Network

• Responses to a single-question e-mail about personal impactsent from August to October 2011, to LAN members who hadbeen active in LAN through at least late 2009.

Data Analysis

Quantitative Data. Likert scale responses about LAN ele-ments (TABLE 3) were analyzed using descriptive statistics(means, standard deviations, ranges).

Qualitative Data. Narrative responses to the open-endedquestions were transcribed verbatim, and information thatmight identify the respondent or the institution was deleted.The masked transcripts of all the comments were read care-fully by one of the authors (L.P. for LAN culture and ele-ments, and D.K. for personal impact data) in an attempt tounderstand and interpret their meaning. Using an inductiveand data-driven analysis process,61 the coders identi!ed a setof emergent patterns and themes that were translated into aset of inclusive but nonoverlapping categories. The categorysystem was shared with the other coauthors and through ex-

tensive discussion the general themes were con!rmed, anda revised, but consensually de!ned set of coding categorieswas agreed upon. All comments were then read and catego-rized by 3 authors (L.P., D.K., G.S.) for purposes of relia-bility. There were relatively few instances of disagreement,and in those cases, discussion between the reviewers tookplace and consensus was reached. Human subjects’ institu-tional approval was obtained from Brandeis University.

Results

Participant Characteristics, Attendance, and Turnover

The initial LAN membership included the 5 deans, 2 exec-utive deans, 3 senior associate deans for academic and fac-ulty affairs, 2 deans for biomedical sciences, 4 departmentchairs (Internal Medicine, Surgery, Obstetrics/Gynecology,and Dermatology), 4 early-career faculty members, 2 gen-eralists, and 3 PhD basic scientists. Fifty-!ve percent werewomen and 25% underrepresented in medicine minority(URMM) members. Similar composition was maintainedover the duration of the LAN.


Pololi et al.

Overall attendance at the biannual in-person LAN meet-ings averaged 66% across the 5 years. Attendance was low-ered by the deans’ rate of attendance, which was 45%. Onedean designated his executive dean to participate in his placesince the dean had assumed additional university roles afterjoining C - Change. Con"icting commitments on LAN meet-ing dates were a problem for the deans.

During the project period, 3 schools appointed new deans,2 of whom subsequently decided to withdraw after 21/2 and3 years’ participation, respectively. A new research-intensiveschool joined the collaboration for year 4. There were alsochanges in LAN members, due to faculty transitions, and 1school chose to rotate members so as to include more faculty.Seven of the original 20 LAN members participated for theentire duration of the project. This article includes data fromLAN members from all 6 schools.

Response Rates

All schools approached agreed to participate, as did allprospective LAN members who were invited to participate.Evaluation response rates were high: exit interview, 95.5%(21/22), personal impact question 85.7% (18/21), and post-LAN paper questionnaire about LAN components and expe-rience, 74% (14/19).

Participant Assessment of LAN Elements

Most elements of the LAN meetings were rated highly (TA-BLE 3). Representative quotes about LAN elements from re-sponses to open-ended questions are displayed in TABLE4. Participants especially valued getting together and shar-ing problems/strategies with colleagues from other schoolsand hearing about promising practices from outside experts.They appreciated the emphasis on collaboration and relation-ship. They valued learning about organizational change ap-proaches and receiving data about their own schools’ cul-ture. They enjoyed the structured dialogue approaches to dis-cussing important concepts. We were somewhat surprisedto learn how important it was for some participants to havetime to meet with LAN members from their own schools. In-volvement of the deans and time for self-re"ection were ratedsomewhat lower, and there was a broad range of opinion forthese items.

Participant Views of the LAN Culture

A key intervention strategy was to create a culture within theLAN that mirrored the culture desired for academic medicinein general, so that LAN members could experience the typeof culture they were trying to create at their own institutions.An important evaluation question, therefore, was whether wesucceeded in creating such a culture within LAN. To try to

answer this question, we analyzed responses to the open-ended questions from our post-LAN questionnaire and exitinterviews (TABLE 2) using the approach described above.

Themes that emerged from the analysis are displayed inTABLE 5 along with representative quotes. Participants com-mented on the relational nature of the LAN as one of itsgreatest attributes. They viewed the LAN as af"rming, sup-portive, inclusive, and diverse. They commented on how theycame to value really listening to others, and to not concen-trate on speaking to get their own opinions across. They com-mented that the LAN environment was safe, trusting, andopen to discussing dif!cult topics. And, !nally, they valuedhow the LAN process promoted their own humanism.

Personal Impact of Participation on LAN Members

To assess the personal impact participation had on LANmembers we analyzed responses to the e-mailed personal im-pact question, as well as the !nal set of questions on the exitinterview, and all questions on the post-LAN questionnaire.For the personal impact question, 15 of 18 respondents feltthat participation in LAN had had a personal impact on them;3 did not. Of the 3 who did not, 2 provided responses thatquali!ed as personal impact in the exit interview. The de!-nitions provided in the personal impact question guided ouranalysis of all data sources, which identi!ed 7 themes.

Participants most frequently described new learning anddeepened understanding of institutional culture, diversity,and inclusion. They identi!ed speci!c areas of deepened un-derstanding such as gender and ethnicity, “the pervasive na-ture of unconscious bias,” the nature of institutional change,and the value of collaboration. Equally frequently, LANmembers commented on the importance of having developednew, valued interpersonal connections both at other and theirown institutions. Next most frequently, respondents men-tioned that they felt supported, energized, motivated, and em-powered to continue their work related to C - Change. LANmembers also described the acquisition of new skills and ap-proaches, and that participation had increased their own self-awareness and personal growth. Some members commentedthat the LAN had fostered in them an emotional connectionto the issues of diversity and inclusion. Importantly, severalmembers reported that they were applying knowledge, skillsand approaches learned in LAN in their own work. TABLE 5displays the themes, how frequently participants made com-ments within each theme, and illustrative quotes.

Discussion

This article contributes to the literature on organizationalculture change in AMCs and responds to calls for cul-ture change efforts20!32 by describing a multi-institutionalapproach that engaged diverse leadership teams in a learning



TABLE 4. Representative Participant Comments on the Learning Action Networka

Attendance at LAN meetings

“. . . the project provided the space and opportunity to step back and examine the challenges and opportunities provided by my institution and its current

leadership. We have, I believe, a window of opportunity to move forward collectively our needed social justice goals.”

“Opportunity to get outside of workplace with limited distractions to really think about the work that I am doing, what it means to me and others, and how

it can be done better (or at least more enjoyably).”

Formal and informal discussion with other LAN members

“Our group discussions have been rich and insightful. While our phone meetings have been good, the face-to-face discussions have been even more

invigorating. . .

“[one-on-one dialogue promoted through paired “Walk and Talk” exercises]. . . useful, engaging, and provocative ... I can remember each one in detail like

they happened yesterday. The opportunity to listen and speak in a totally free environment was something that does not happen at one’s institution.”

Structured methods for deepening dialogue

“Our periodic use of Appreciative Inquiry and similar structured forms of dialogue (such as Knowledge Cafe) really gave me an appreciation for the

importance of listening carefully and without interruption to the ideas of others. I used to break in to conversations and spend time thinking about my

own position/thoughts rather than listening to others.”

Time to meet with LAN members from own school

“People rarely get together at own institutions to discuss these matters outside of LAN . . .Would like 4–8 hours at each LAN meeting set aside for

members to get together with people from OWN institution.”

Re!ective practice

“The most powerful lessons have come from our collective re"ection on our work. C - Change has created the space to not only re"ect as a group but

also as individual leaders. Through re"ections—collective and personal—I have gained insights, learned new perspectives and retooled for the work

ahead.”

“I appreciated the power of stories and poetry to connect us.”

“Poetry and self-re"ection not a great hit. . .At a fast-moving, low resource place, people felt they didn’t have time for this.”

“ . . . the slow pace was frustrating—there were no observable objective outcomes de!ned.”

Data action cycles

“I now have data needed to help drive important change.”

“The survey offered us extremely important information that will be critical to explore further and act upon.”

Inclusion of the deans as participants

“Dean used it [C - Change] as leverage”

“With a new Dean coming, it’s hard to know whether momentum will be maintained or even changes rolled back.”

Having the deans present “impeded faculty-driven change.”

Work between LAN meetings

“IWGs were different than LAN meetings, they were like parallel tracks—more oriented toward products and concrete ideas—running these in parallel

helped generate creative ideas and keep them going—satiated the need of some for ‘doing something.’ ”

“Ongoing [liaison] calls kept us focused, kept momentum going to follow through and have something to show self and others.”

“Problem was that you were encouraged to work on these things between meetings, but once you got back home you became overwhelmed with other

things.”

Relation between LAN and interview/survey studies

“I would have liked the invitation to be involved in some of the scholarly work that came out of the project. It seems that there was a disconnect between

the LAN and research team that might have been bridged a little more effectively.”

aIncludes the responses of (a) 21 of 22 LAN member exit interviews, and (b) post-LAN evaluation questionnaire: 14 of 19 LAN members active at the timeof the !nal LAN meeting.LAN = Learning Action Network; IWG = Innovation Work Group


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TABLE 5. Themes Related to Participants’ Perceptions of the Learning Action Network (LAN) Culturea

Relational

“The most positive aspects were personal relationships developed”

“The connections with others and the opportunity to deepen relationships are strong incentives . . . [to keep returning]”

Af"rming and supportive

“It has been very important to me to meet and get to know others who are facing similar challenges and problems. The support we give each other has

been one of the most important bene!ts of this national initiative.”

“It has left me reaf!rmed in using my leadership role to address race/ethnic diversity of my faculty.”

Collaborative

“I’ve learned about the value of community—the importance of being with “kindred souls” who share a common sense of purpose.”

“Made us feel less isolated, part of something larger”

“A great opportunity to network and meet others who are struggling with the same challenges—we don’t often get that opportunity.”

Inclusive and diverse

“Most people I’ve met here are individuals I would never have encountered otherwise. Their perspectives have not always been mine and learning

from them has broadened my own perspective.”

“The wonderful work a diverse group of passionate, knowledgeable people can create.”

Respectful, really listening to others

“Reinforced that one learns more by listening than speaking.”

“The importance of really listening to other people.”

Safe, trusting, open to diverse perspectives

“It’s rare to have these issues discussed explicitly.”

“With trust and openness we discussed and confronted very dif!cult and sometimes painful issues.”

Humanistic

“When we shared stories. . . personal experiences are so compelling and allow us to relive a de!ning moment through the lens of a trusted colleague.

This was particularly true of the stories related by women and minority colleagues about the barriers they had to face.”

“. . . created a community, nurturing the humanity in all of us.”

aIncludes the responses of (a) 21 of 22 LAN member exit interviews, and (b) post-LAN evaluation questionnaire: 14 of 19 LAN members active at the timeof the !nal LAN meeting.LAN = Learning Action Network.

community.41 A previous publication has described an inter-vention at a single medical school33; we are not aware of anymulti-institutional efforts described in the literature.

We hoped participants would become engaged in creat-ing a relationship-based, inclusive, collaborative, af!rming,and humanistic LAN culture, based on the assumption thatthe culture created in the LAN could be brought back andmodeled in their home institutions. The learning communitywas designed to create a microculture in which participantswould experience values, behaviors, and practices congru-ent with those desired for their own institutions, and prepareparticipants to undertake the complex process of changingorganizational culture in their respective institutions.

The !ndings described in this paper suggest that partici-pants came to recognize and value the culture that was cre-ated in LAN. They reported developing a deep understand-

ing of the relevance of organizational culture to the advance-ment of female and URMM faculty. They formed valued re-lationships. They described becoming more motivated andresilient, and experiencing a trustworthy and collaborativenetwork. Even though our intervention model did not stressskill de!cits, it is notable that skill acquisition was reported inrelational, collaborative behaviors, and personal awareness.Finally, participants reported applying new learnings in theirwork.

Trust is often lacking in the current culture of academicmedicine, even though a high level of trust is a hallmarkof successful health care systems62,63 and has been linkedto improved performance in education.64 Trusting environ-ments that invite diverse opinions and where all faculty feelthat they can be open without feeling threatened, should bea goal in academic medicine. The LAN sought to provide



TABLE 6. Themes Related to Personal Impact of Participation on Learning Action Network (LAN) Membersa

Transformational thinking/deepened understanding/new perspectives (61%, 43%)

“I came to realize that there were things we were taking for granted—that others felt abused and isolated, and that the way to overcome this is to

invite people in, to make people’s lives better and to make them feel they were part of the process.”

“It gave me an awareness and insight into the complexity and subtlety of the issues . . . it broadened my horizons, opened my eyes.”

“I believe I have gained a better understanding of some of the huge cultural barriers facing minority faculty in the current academic milieu.”

“C - Change was . . . an important tool to help me learn . . .what it takes to be an institutional change agent.”

New valued interpersonal connections (39%, 57%)

“The relationships developed through C - Change have . . . played a large role in my professional growth, success and resilience.”

“[C - Change] . . . has helped me to learn more about the colleagues at my own institution in ways not possible at our workplace.”

Increased support, motivation, and resilience (22%, 33%)

“I felt less isolated in my desire to move forward on some [of] these issues. C - Change also gave credibility to the work several of us were doing at

[my institution].”

“It’s rare to have these issues discussed explicitly among like-minded people. Made me feel empowered.”

“Development of a professional safety-net has helped increase/expand my resilience overall.”

New skills and approaches (22%, 29%)

“Learned about how to engage groups when discussing career opportunities for women and men in a more balanced manner “

“I learned about “Knowledge Cafes” as a technique, and the power of re"ection”

“Developed re"ective skill set”

“The LAN experience made me re"ect on the power of storytelling—a learning that I hope to carry forward and use productively.”

Increased self-awareness and personal growth (22%, 14%)

“Our discussions and featured speakers did help me to think more deeply about unintended biases in my own thinking.”

“I am very aware of the ways I may have contributed, often unwittingly, to the negative experience of some faculty.”

“In learning to have a better sense of myself and different ways in which to articulate the messages, I became a better leader.”

Emotional connection to issues of diversity and inclusion (17%, 5%)

“. . . prior to C - Change, I had only an “intellectual” understanding and appreciation of the challenges and barriers, both to individuals and

institutions, created by bias, ie, I had no !rsthand experiences. However, through my interactions with several individuals in the C - Change

community who actually experienced, confronted and overcame these challenges, my understanding became personal and “real.” Their stories

made me acutely aware of both the personal pain and loss of institutional potential created by unintended bias, which I believe makes me more

effective in carrying out the duties of my position.”

Application of new learnings (22%, 19%)

“It’s allowed me to set up initiatives on hiring and bias based on ideas from [promising practices presentations].”

“. . . it has had a very positive effect on my relationships and mentoring, which is much more genuine than it may have been before this process.”

“I !nd myself reaching out to individuals or groups of faculty who clearly feel unengaged in the institution and demoralized by the demands of

academic medicine.”

“I now have a new faculty development talk within orientation during which I get to talk about unconscious bias.”

“I am . . . involved in developing a new mentorship program directed at URMM faculty and Clinician Educators . . . .”

aResponse rate: 85.7% (18 of 21) and 95.5% (21 of 22).bPercentage of respondents with responses falling within a theme area for the personal impact question and exit interview, respectively.LAN = Learning Action Network; URMM = underrepresented in medicine minority.


Pololi et al.

experiences to support this development, and our evaluationsuggests many areas of success. As Remen65 has eloquentlydescribed, the “heart” is often seen as an unprofessional dis-traction or vulnerability in the cognitive ethos of medicine.In contrast, LAN members were able to authentically speakfrom the heart to colleagues about the meaning and experi-ences of their work, thus creating trust.

In interpreting the !ndings from this report, readersshould be aware of some limitations. The assessments of theLAN, its culture, and the personal impact on participants re-lied on self-report and are liable to recall and attitudes of sub-jects (Hawthorne effect) biases. Because we used qualitativeanalysis of open-ended questions, we cannot provide infor-mation on what percentage of participants held speci!c opin-ions. However, !ndings reported were always mentioned byseveral participants, and frequencies are reported. Becauseresponses were to open-ended questions, the frequency ofsimilar responses likely underestimates the number of partic-ipants who would have agreed with a speci!c perception. Wechose predominantly qualitative methods to enable a context-rich, formative assessment, and to enable identi!cation of!ndings not speci!cally hypothesized. Finally, the evaluationpresented in this article does not address impact at the par-ticipating schools; that is the focus of another report.39

Challenges and Lessons Learned

As expected with any innovative and ambitious project, wefaced challenges and learned lessons in the process of theLAN initiative.

Adoption of Re!ective Practice and Emergent Design

Initially, LAN meetings engaged participants in exercises de-signed to make them more self-aware, and re"ective aboutcultural issues related to inclusion and diversity. While thisapproach resonated positively with some, other, more task-oriented members were impatient and uncomfortable withthese methods. Emergent design helped us correct course.We achieved the goal of creating a more re"ective cultureby integrating well-received structured dialogue approaches,such as Appreciative Inquiry, and Knowledge Cafe, whichinvolved the familiar approach of review and discussion ofarticles related to mindfulness, bias, and culture change, andthen generalizing to experience. Gradually, as openness andtrust (an additional goal) developed among LAN members,some members divulged their own painful stories. The storieswere discussed by the group and stimulated further re"ectionand introspection. Another example of where emergent de-sign was helpful was that after receiving feedback about howmuch LAN members valued convening with members fromtheir own schools during LAN meetings, we protected time

for this during subsequent meetings. We also included work-in-progress sessions in response to the feedback.

Membership Transitions

Unavoidable faculty turnover interfered with the continuityof relationships and created the ongoing need to integratenew members. Particularly disruptive was the turnover of 3deans. Although C - Change was not a “top-down” inter-vention, the turnover of deans indicates that a commitmentto change must become widely embraced to ensure continu-ity that endures leadership change. Speci!cally, engaging abroader base that includes not only the dean but also otherkey stakeholders from the beginning might be a wise ap-proach for any culture-change effort lasting several years.

Funding Support for Change

Several LAN members commented on their dif!culty priori-tizing time for the project in their home institutions betweenmeetings while overwhelmed with existing responsibilities.Accreditation issues and the !nancial crisis of 2008 createdfurther diversions. We planned to !nance faculty time andprojects at the schools but did not have the funding to doso. Funding for work within schools should be consideredfor similar future efforts. Given the slow nature of culturechange, it would have been advantageous to resource theLAN for an 8- to 10-year funded change process.

Research Participation

Involving LAN members in C - Change research might havebeen a way to increase engagement, similar to a “community-based participatory research” approach and aligns with effec-tive approaches to change in complex organizations.59 OneLAN member became a part of the C - Change Survey Re-search Team, and others have participated in C - Change pre-sentations and scholarship, but we were unable to make theresearch effort of C - Change as broad-based as we wouldhave liked.

The core changes in the culture experienced by LANmembers encouraged trustworthy relationships and sup-ported their humanistic needs and values. As such, it sup-ported faculty in ful!lling professed goals, in contrast tothe present culture that presents barriers.1,3,7,15,24 We believethat, notwithstanding the challenges, the C - Change LANachieved its purposes of (1) transforming the way leader-ship teams from constituent academic medical centers ex-perienced and understood organizational culture and diver-sity, and (2) motivating and empowering members as changeagents in their home institutions. It has also demonstratedthat multi-institutional efforts are feasible and have someadvantages.



Lessons for Practice

• A purposefully diverse group of faculty andleaders can build a community of trust tosupport culture change activities.

• Experiencing a humanistic, relational, af-firming and inclusive culture is valued bymedical school faculty and leaders.

• Participating in a trustworthy learning com-munity can deepen understanding and helpcultivate an emotional connection to issuesof diversity and inclusion.

• Faculty can learn the attitudes, skills andbehaviors to help improve the culture of aca-demic medicine.

Most of the methods used in this project (eg, focus onvulnerability and af!rmation, re"ective practice, dialogue,Appreciative Inquiry, Knowledge Cafe, and data-action cy-cles) involved principles of signi!cant and adult learningelucidated by Brook!eld,44 Fink,66 Knowles,67 Mezirow,68

Palmer,69 Rogers,43 Schon,47 and others. These principlesinclude establishing a safe environment where all can begenuine and open, creating a learning community where alllearn from one another; self-direction; facilitation of learn-ing rather than teaching; active in contrast to passive learn-ing; connection to experience; re"ection; empathic listening;and focus on the emotional, attitudinal, and behavioral di-mensions of learning in addition to the cognitive. Some ofthe methods used may be especially relevant to challeng-ing areas in continuing education across various health pro-fessions that would bene!t from transformational thinking(eg, systems improvement); training in teamwork and col-laboration (eg, quality improvement, team care, and cross-disciplinary research); emotional connection to a topic (eg,enhancing empathy in health professional-patient interac-tions); and self-awareness (eg, training in communicationskills, professional development).

We hope this report will stimulate further discussion andwork in the important area of improving the culture in aca-demic medical centers for many health professions, and thatit stimulates further interest in the processes described.

Acknowledgments

The authors would like to acknowledge the contributions ofMichael Goldstein, MD, who helped plan and organize theLAN meetings during the !rst half of the project; and the col-lective efforts of the deans and the C - Change LAN mem-

bers at the participating schools. The authors thank all themembers of the C - Change research team who supportedthe process of C - Change work.

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Documents

Preparing Culture Change Agents for Academic Medicine in a Multi-Institutional Consortium: The C - Change Learning Action Network