Change Management and Innovation in Graduate Medical Education
Making meaningful and innovative change in graduate medical education (GME) is often difficult, fraught with roadblocks at multiple levels, requiring a great deal of time and effort, as well as social or political capital. Due to the myriad of challenges to implementing change in GME, ranging from institution-level recalcitrance to systems-level regulatory issues, there is a paucity of pragmatic change implementation frameworks and examples of successful large-scale innovation in the GME literature to guide those hoping to make meaningful and substantive change. We will propose several innovative approaches to large-scale change in the GME space and provide examples of success, obstacles overcome, and lessons learned from a consortium of GME programs and institutions as part of the American Medical Association (AMA) Reimagining Residency initiative.1 These change initiatives span the transition from medical school to residency, across the entirety of the GME landscape, and into the transition from GME training to unsupervised practice and initial certification.
Projects funded by the AMA Reimagining Residency initiative attempted to address some of the most pressing challenges facing GME in the United States today (Table 1). These include addressing the physician shortage in rural and underserved areas,2,3 improving the implementation of the systems-based practice core competency,4,5 establishing true competency-based education and assessment,6,7 and improving the undergraduate medical education (UME) to GME transition.8-10 Given the complexity, size, systemic structural, and persistent nature of these challenges, it was necessary to explore and utilize a variety of novel change management approaches in order to begin making meaningful long-term change within GME.11
Change management is the process of guiding organizational change to fruition, from the earliest stages of conception and preparation, through implementation and, finally, to resolution.12 There are a number of options for approaching change in GME, each with its own unique uses, benefits, and potential pitfalls. Here, we discuss several potential options (Table 2) and provide examples of when they might be of optimal use, considerations for the challenges that each approach may present, and examples of where they have been or might be used from the literature (Table 3).
Lessons Learned From the AMA Reimagining Residency Consortium
Each of the members of the AMA Reimagining Residency consortium chose to utilize at least one large-scale change management strategy in order to implement their initiatives. Whether these were at the institutional level, across multiple institutions, or across whole specialties, each grantee began with one or several frameworks in mind. The benefits and challenges of each change management framework are discussed here, along with examples directly from the grant projects.
1. Kotter’s 8-Step Change Model13
The most often utilized approach to change in medical education is Kotter’s 8-Step Change Model. This model is tried and true for creating change within a given program. The grant initiatives that employed this model did so given their scale (one across an entire institutional enterprise and the other across an entire specialty) and the myriad of stakeholders needed to buy in (regulatory bodies, licensing bodies, hospital credentialing, national governing bodies, and others; online supplementary data). The Mass General and Brigham Promotion in Place team was successful in getting multiple local specialties with champions to buy in to the guiding coalition. However, challenges emerged with certifying and licensing bodies for multiple willing specialties. The pathology residency program was able to successfully leverage Kotter’s model to move forward with promoting residents in place, while others ran up against resistance around the need for change and structural barriers. The Association of Professors of Gynecology and Obstetrics Right Resident, Right Program, Ready Day One team was highly successful in building a guiding coalition across organizations, uniting around a core strategic vision, and celebrating wins along the way to sustain momentum. In this way, Kotter’s framework facilitated an essential model around which to scaffold large-scale change across the entire specialty of obstetrics and gynecology.
2. Readiness for Change Assessment14,15
Assessing a GME program’s readiness to change prior to initiating a change management process, allows programs with the most readiness to be identified to optimize engagement and chances of success. Doing this emphasized the need to assess readiness prior to beginning any change management project. The Advancing Systems-Based Practice Implementation team identified this as the most essential component of their change process. By identifying programs within the 3 GME systems engaged with their project using this approach, they were able to delineate where to implement their initiative to gain a key foothold and begin to expand more broadly, using successes from programs that were ready, and identifying what within those programs made them fertile ground for successful implementation.
3. Design Thinking16
Design thinking is a human-centered approach to problem-solving that begins with the end user and their needs in mind. Design thinking is known to be advantageous in generating creative solutions to long-standing issues or obstacles by using a “backward design” approach. Backward design begins with the end user’s needs and uses the design thinking approach to craft a solution that meets those needs. While design thinking can be highly successful in the right circumstances, not all grant programs found it to be useful due to the time commitment necessary to meaningfully engage in the design thinking efforts. The University of North Carolina Fully Integrated Readiness for Service Training (UNC FIRST) team used it with some success in engaging with stakeholders to create unique solutions to workforce problems in North Carolina. However, they had already established significant buy-in from stakeholders. On the other hand, the Advancing Systems-Based Practice Implementation team found design thinking not to be an effective change management approach within GME for their project due to the lack of time residents and program leadership had to participate in design thinking efforts as end users.
4. Implementation Science17
Implementation science provides a conceptual framework to incorporate key informant inputs while using evidence-based approaches to answer key questions that impact the implementation process to facilitate successful adoption of an intervention. By using process cycles that consider internal and external factors that facilitate or challenge the implementation process, one is able to move toward adoption over time by addressing key barriers and bridging inputs and processes. The Competency-Based Medical Education (CBME) in Emergency Medicine project leveraged implementation science to great effect to address a complex change process across multiple programs and move toward whole-specialty adoption of the change. Using implementation science allowed the team to work with their local GME offices and institutions as well as national organizations to anticipate and address challenges around policies and culture that would have otherwise impeded this initiative. While not all challenges could be avoided, early mitigation strategies using an implementation science approach were highly effective.
5. Logic Model18
A logic model is an approach to considering a problem or situation, the needs and assets to address that problem or situation, and the key players involved in a way that breaks down the core components and steps required to operationalize a large-scale change initiative or innovation. Both the UNC FIRST and California Oregon Medical Partnership to Address Disparities in Rural Education and Health (COMPADRE) teams used a logic model to frame their change management approach to addressing the rural workforce shortage. These programs sought GME and community partners to address the health needs of rural underserved patient populations by training residents within these communities. This required significant organization toward achieving these large-scale change outcomes. Both programs thought that the use of the logic model for their processes was helpful in organizing people and resources toward their ultimate outcome, though it was not sufficient to sustain momentum by itself.
6. Realist Evaluation19
Realist evaluation examines the relationships between context, mechanisms, and outcomes. It asks, “What works, for whom, and in what context?” This approach is ideal for innovations and large-scale change that will be applied across different contexts for which there is likely acceptable variability that you want to capture to optimize an adaptable approach to implementation. Both the UNC FIRST and CBME in Emergency Medicine teams utilized a realist evaluation approach within their projects. UNC FIRST employed a great deal of flexibility in deploying their workforce intervention across different systems and therefore desired to examine outcomes and their variability across those systems. The CBME in Emergency Medicine team implemented the core components of CBME variably across pilot sites, examined variability of implementation, and is now using that experience to inform implementation across all emergency medicine training programs, creating even more heterogeneity. While not particularly useful in planning initial change in either instance, realist evaluation as a change framework is essential to drive future scaling of change when substantive context variability can be expected.
While things often did not go exactly according to plan within each project’s change process, these approaches provided necessary scaffolding and each grantee was able to affect meaningful change over the course of the funding period. While much work remains to be done, several of the members were able to reflect on their strategies, successes, and lessons learned, available as a Table in online supplementary data.
What is clear from these experiences, however, is that no single change management strategy can act as a “magic bullet.” The most successful projects leveraged multiple change management frameworks or were able to pivot to another framework when the first fell short. As such, it is key to examine the change you wish to implement, the context in which you will implement the change, and your current stakeholder buy-in, as well as to ensure that you and your team are prepared to be flexible throughout the process.
Key takeaways from each grant team coalesced around several change management themes. The value of collaboration and frequent communication across stakeholders was the cornerstone of many successes experienced in each project. By leveraging these relationships and involving stakeholders at each step within the given change management framework, each grant team was able to achieve buy-in and work to achieve a scalable innovation. It is imperative to note that celebrating early wins kept stakeholders engaged throughout the process and continued to bolster support. Finally, adaptability throughout the process is key, as large-scale innovation will always involve curveballs. Building teams that can respond by mitigating challenges and pivoting into new directions helps break down barriers and catalyzes continued momentum toward the intended change.
Author Notes
