Armstrong, Elizabeth G. PhD; Barsion, Sylvia J. PhD
In this article, we discuss calls for significant change in the delivery and impact of health care education, and we suggest a strategy to foster the environment and develop the skill sets required for designing and implementing such change. The strategy is for health care education program leaders and faculty to teach five research-based innovator skills. We use the Harvard Macy Institute (HMI) program to illustrate how leaders can implement the strategy successfully.
Changing Health Professional Education
The Lancet Commission on the Education of Health Professionals for the 21st Century1 makes a strong case that health professional education must be redesigned to bring about change that has a “global outlook, a multiprofessional perspective, and a systems approach.” The authors of that report argue that meaningful change occurs when health care professionals experience “transformative learning” (developing the leadership skills necessary to become enlightened change agents)—rather than just the “informative learning” (acquiring the knowledge and skills to become experts) and “formative learning” (socializing with others in the field and absorbing values to become professionals) that the Lancet Commission authors found to be the norm in many health professional education settings.
The Carnegie Foundation for the Advancement of Teaching, on the basis of two major studies on the academic preparation and training of physicians and nurses, makes assertions consistent with those from the Lancet Commission. The 2010 report on educating physicians2 asserts that medical education is flawed: It is not learner-centered and does not take advantage of the insights gained from learning sciences; it makes “poor connections” between formal knowledge and experiential learning, and it fails to develop habits of inquiry and innovation in learners. The study of nursing education3 identifies many significant problems including an inadequate quality and quantity of faculty development opportunities; too little focus on the scholarship of teaching and learning; not enough support for teaching the skills of inquiry, reflection, and research; and systems that do not support students in becoming agents of change. To illustrate, the report on nursing education3 reads, in part,
In order for today’s students to be prepared to meet the reform challenges in practice settings—and be influential leaders in the political and public arenas for improved health care systems—they will need to learn theories of organizational development and policy-making, as well as strategies to change organizations.
The challenge for health care educators is how to take the multiple calls for transformational change and actually foster the environment and develop the skill sets required to design and implement major innovations. More health care educators and health care delivery system leaders must not only become innovators themselves but also develop systems that will support the next generation of innovators.
The Innovator’s DNA
In The Innovator’s DNA: Mastering the Five Skills of Disruptive Innovators, Dyer et al4 identified behavioral and cognitive “discovery” skill sets that make up the “innovator’s DNA.” On the basis of interviews with nearly 100 innovators, as well as on comprehensive analyses of innovative businesses, they identified and comprehensively characterized five discovery skills that ignite successful innovation: (1) associating, making surprising connections across areas of knowledge, (2) questioning, breaking out of the status quo and considering new possibilities, (3) observing, detecting small behavioral details that suggest new ways of doing things, (4) networking, finding and testing ideas with individuals from diverse backgrounds in order to gain radically different perspectives, and (5) experimenting, relentlessly seeking new experiences, trying on new roles, and exploring the world. One of Dyer and colleagues’ major findings is that although innovators typically have or develop the five competencies on their own, these five skills can be taught and learned.
Herein we use the prism of the innovator’s DNA to examine a continuing professional development (CPD) program for health care educators, the HMI—the overarching purpose of which is to develop skills and create a mind-set in participants (scholars) that encourages them to build their own educational models customized for implementing change in their home institutions and in their fields.
Launched in 1995, the goal of the HMI is the same today as when it began: to enable participants both to put into practice self-directed learning and to build their own educational models customized for implementing changes in their home institutions. Rather than a “cookbook” or one-size-fits-all approach to educational innovation, the intent was to build capacity to promote sustainable, institution-specific change.
The HMI offers four courses, each held annually at Harvard University5,6:
1. Program for Educators in the Health Professions (an 11-day winter session and a 6-day spring session, with progress on a required project monitored by an HMI faculty member between sessions),
2. Leading Innovations in Health Care and Education (a 6-day session in June),
3. Systems Approach to Assessment in Health Professions Education (a 6-day session in March), and
4. Starting in 2013, Become a Digital Citizen—Technology in Health Care Education (a 5-day course in October).
Each course features journal clubs; project groups with step-back consultation (a short presentation by a scholar on his or her project plan followed by immediate feedback from colleagues, including their suggested strategies for implementation and evaluation); large-group interactive sessions during which scholars discuss case studies drawn from business, public health, engineering, and education; and small-group discussions. The HMI faculty teach and model the skills of educators and innovators by explicitly inviting scholars to observe and consider which of the many teaching strategies in use have potential in their own settings. Focused discussion of and reflection on HMI practices stimulate scholars to invent new strategies and create plans to practice differently at their home institutions. The faculty encourage scholars to raise probing questions, to study innovation and change management, to reflect on the material and its possible application in their lives, and to learn from colleagues. Scholars are challenged to examine any personal and organizational assumptions that form barriers to change and to identify options that foster “transformational learning.”7 Theories from the fields of business and organizational development, such as disruptive innovation (i.e., a process by which a product or service takes root initially in simple applications at the bottom of a market and then relentlessly moves up market, eventually displacing established competitors)8 and systems thinking, become part of the scholars’ powerful arsenal of tools for understanding the options for and implications of organizational change.
To force scholars out of their comfort zones, the HMI includes a strong experiential component that begins with the application to the program. HMI applicants must define a project or identify an institutional challenge, vetted by their home institution, that they plan to act on when the course is complete. Project topics occur across the education and health care continuum (e.g., new learning technologies, assessment strategies, institutional policy change). Throughout the course, scholars think about how to apply theories and methods from multiple disciplines to solve the real problems occurring at their home institutions. As they devise plans to implement changes, they receive constructive, specific feedback both from faculty and from fellow scholars. Scholars use the project or challenge throughout the program as the centerpiece for testing principles and theories within the context of their own local realities. Because the projects and problems are individual, HMI faculty neither advocate a single template for solutions nor proscribe one methodology for arriving at solutions; rather, participants determine what action(s) will best address their individual needs as well as those of their institution.
At the end of the winter session, participants in the Program for Educators in the Health Professions write their own personal and institutional strategic action plans. These plans constitute commitments to action between the scholars and HMI faculty and include a requirement for the scholar to present a scholarly poster and abstract about their project during the spring session. Scholars often have contact with HMI faculty between the winter and spring sessions and after the course is completed (e.g., seeking assistance for completing scholarly papers, asking for networking suggestions, participating in multinational and interinstitutional collaborations). Examples of the kinds of changes that began with an HMI project idea include an academy for health care educators, interprofessional workforce development planning for new faculty, and competency-based graduate medical education program.
In 2010, HMI leaders conducted an online, retrospective survey of alumni from the three then-extant HMI programs for health care providers and educators (listed above). Harvard Medical School’s institutional review board deemed the project, which occurred as part of a review of HMI’s first 15 years (1995–2010), to be exempt research. The population of health care provider and educator alumni was 2,200, and e-mail addresses were available for 1,572 (71%) of these past scholars. Of these 1,572 alumni, 606 scholars (39%) responded. In addition, in 2010 and 2011, HMI leaders conducted structured telephone interviews of 67 past HMI participants. Alumni from each of the three courses and from across the 15-year period were randomly invited to participate in the interviews.
A caveat in interpreting these data is that no information is available from those participants with whom HMI had not been able to sustain contact; thus, generalizing the findings herein to all HMI participants is inappropriate. Further, our intent was to gather descriptive data rather than conduct a quasi-experimental or experimental study, so ascribing causation is not possible. That said, the quantitative survey evaluation findings, coupled with the open-response feedback from alumni on the survey and during the interviews, provide consistent evidence that hundreds of scholars became more involved in health care education and innovation after participating in HMI. Importantly, the scholars themselves attributed the reason for their change to their experiences at one or more of the HMI courses.9
We have culled, from the extensive evaluation data available, the qualitative and quantitative findings most relevant to the innovator’s skills, and we have presented them here with further information both on each of the five competencies and on how HMI faculty seek to teach these competencies, practice them, and ensure that they become part of the repertoire of all scholars. We took the illustrative quotes, verbatim, from open-ended responses to the survey and interview questions, which afforded participants the opportunity to explain their experiences in their own words. We also include data from two closed-ended items. The responses to one item—“When you think of the HMI course you took and other continuing education courses you have taken, how does the HMI course compare?”—shed light on whether and how well innovators skills were taught in HMI courses compared with other CPD courses the respondents had taken. A second question listed instructional strategies that HMI uses and asked respondents to indicate whether they felt any of 10 CPD strategies (such as “learning in small groups” or “developing a new network of colleagues”) were unique HMI strengths. Here the intent is to examine how innovation skills are taught.
Building the Five Innovation Discovery Skills
Skill 1: Associating, making surprising connections across areas of knowledge
According to Dyer et al,4 making unexpected connections is central to innovation and requires the innovator to create the time and circumstances to experience different ideas, individuals, and organizations. They write, “when the brain is actively absorbing new knowledge, it is more likely to trigger connections between ideas.” Having a place, concentrated time, and opportunity—such as is afforded through the HMI—for new experiences and reflection, removed from the day-to-day workplace, facilitates associating.
When HMI began, the program director observed—and, according to their end-of-course evaluations, many scholars during the early years of the program concurred—that most CPD programs for educators in health care professions were held within a single department or institution (i.e., a hospital or school), led by someone from that institution, and, hence, afforded participants little or no opportunity to learn from others outside the organization, which limited the range of possible solutions to a given problem and may even have masked the fact that there was a problem. HMI brought together health care professionals from different institutions, countries, and disciplines and introduced multiple opportunities to talk, learn, and reflect on common and unique challenges. Most survey respondents (90%) viewed HMI as better at “fostering reflective practices” than other CPD courses they had taken. Scholars valued seeing a situation in a new light:
For us, the interface with the Schools of Business and Education presented at HMI directly impacted our faculty’s knowledge and ability to operate outside the provincialism of our own discipline. Without being able to imagine the collaboration of the School of Medicine and School of Nursing, none of this important educational work would be serving our students today (emphasis added).
HMI programs require reading and discussions designed to go well beyond scholars’ usual academic experiences. One scholar describes the experience:
Whether teaching, facilitating discussions, trying to generate ideas, redirecting ideas, you are working with curricula at such a different level, it explodes your thinking each time.
Further, 65% of all survey respondents reported that “reading literature outside of fields” they usually peruse was a unique strength of HMI, and 83% of those who took the Leading Innovations course identified “exploring/applying concepts derived from business” as a unique HMI strength. Scholars appreciated the exposure both to new fields and to the HMI faculty (87% identified the faculty as a unique strength) who represent diverse disciplines including business, engineering, instructional technology, and educational outcomes measurement. To illustrate, one scholar commented:
The most substantial impact for me was adding a business-oriented perspective to my educationally oriented experience. This, coupled with a new language related to innovation and change, has been very effective in giving me ways to get my institution’s administration on board. I also have a broader understanding of ways in which the challenges I feel as a health professions educator mirror those faced by other professions, thus increasing my view of potential collaborations.
Skill 2: Questioning, breaking out of the status quo and considering new possibilities
Dyer et al4 write that questioning is the “creative catalyst for the other discovery behaviors.” True innovators ask probing and provocative questions that keep coming at a problem from different and unexpected angles. Although questioning alone does not mean the results will be innovative, pushing stakeholders to ask as many questions as possible about the problem, rather than rushing to brainstorm a solution, will increase the likelihood of breaking out of the status quo. Questioning is a systematic way of thinking and avoids the mistake of coming up with a seemingly brilliant solution to the “wrong” question.10
Faculty use the projects that scholars bring to HMI not only to encourage scholars to question the status quo at their own institutions but also to provide an opportunity for other scholars and faculty alike to offer insights as they inquire about the rationale behind each scholar’s project and the proposed solution. One scholar explains:
In order to get into the program as a participant, you need to have a project in mind: This makes you think about how you can apply what you’re being taught directly to the project that affects your life. That makes you a more active learner and a more active participant.
Scholars envision new possibilities through their discussions with faculty and one another. Over three-quarters of respondents (81%) thought HMI “supported feedback from colleagues” better than other CPD programs. To illustrate, one scholar reports:
The first valuable lesson I learned at HMI is that it is not where you sit on the hierarchical ladder that empowers you: Wherever you are, empowerment comes from your ability to see beyond your position. Suddenly every challenge looked like an opportunity to me. Terms like “lack of resources,” “credential barriers,” and “cultural barriers” were miraculously erased from my dictionary.
As preparation for using the Harvard Business School large-group case method11,12 (through which students read the case study in advance and discuss it later in class with one another while the professor encourages dialogue and helps analyze and summarize findings), scholars receive instructions about the value of and techniques for actively listening to one another. A heightened understanding of varying perspectives helped the scholars consider new ways of thinking about a question or problem before considering potential solutions.
Scholars are not the only ones considering new possibilities. As faculty listen to scholars’ questions and learn about their projects, they are challenged to create new case studies, readings, exercises, and learning strategies that align with the current and projected needs of the HMI community.
Skill 3: Observing, detecting small behavioral details that suggest new ways of doing things
Dyer et al4 believe that innovators take themselves out of their routine environments and create opportunities to see through the eyes of others; they are careful observers, curious to see firsthand how different stakeholders react to the same situation or how various organizations handle similar problems. By observing what does and does not work and by puzzling over differences from prior experiences, innovators sharpen their observational skills.
HMI incorporates exercises through which scholars observe teaching sessions. First, the scholars collect data about the sessions (e.g., Who is sitting where? How much time is spent in discussion versus lecture? What types of questions are asked and by whom? How many students are involved versus tuned out?). Next, scholars analyze and interpret the observational data, and then they reflect on their own values, asking themselves to observe their own reactions (e.g., Why do I feel that way? What does my reaction tell me about myself and my beliefs about learning?). Such self-observation provides a window into one’s own assumptions and values, which in turn, opens up the potential for seeing new possibilities.
The underlying teaching style has allowed me to have insights into my unrecognized biases, question my assumptions, and freed me to consider a broader spectrum of options to promote my goals … true on a personal, as well as professional level.
Skill 4: Networking, finding and testing ideas by meeting with individuals from diverse backgrounds in order to gain radically different perspectives
Dyer et al4 discuss how innovators build relationships and networks. Innovators go out of their way to meet people outside of their field. Individuals who network to meet people inside their field are typically seeking access to resources or ways to advance their careers. In contrast, “idea networkers” seek out individuals who are not like them in an effort not only to gain new perspectives and learn new things but also to test ideas. A researcher analyzing innovation at Bell Labs13 found that
Most feats of sustained innovation cannot and do not occur in an iconic garage or the workshop of an ingenious inventor. They occur when people of diverse talents and mind-sets and expertise are brought together, preferably in close physical proximity where they can have frequent meetings and serendipitous encounters.
Eighty percent of the survey respondents reported that the HMI program was much better in “encouraging teamwork” than other continuing education courses they had taken. Scholars’ experiences with HMI were shaped by their fellow participants who represented a range of professions (e.g., clerkship directors, directors of nursing education, veterinarians, ministers of health, pharmacists, medical school deans) who work in institutions from across the world. Since HMI began, scholars have represented over 400 institutions from more than 100 countries (including Australia, Singapore, the Netherlands, Chile, Saudi Arabia, Canada, Mexico, India, Taiwan), and numerous collaborations have occurred as a result. Two scholars specifically noted the advantages of such collaboration:
We have many opportunities within our specialties but few across specialties and even cultures and countries. My personal/professional growth as a consequence has contributed to my ascent to leadership.
The collaboration with other educators from around the world was both empowering and affirming. I was more confident about my ability to contribute to the education system in my home institution.
HMI has nurtured an ongoing community of scholars both through frequent personal contacts and through reunions at national and international meetings of professional associations. With the growth of social media, virtual networking has added new opportunities and dimensions to communicating during and after the course. Scholars and faculty now send Tweets to colleagues during classes to share ideas, resources, or URLs. They use LinkedIn and Facebook to maintain connections made at HMI and to build new networks after the course is over. HMI is evaluating alternative ways to use social media more deliberatively during courses and to use electronic networking to bring alumni from different cohorts and from diverse backgrounds and perspectives together.
Skill 5: Experimenting, relentlessly seeking new experiences, trying on new roles, and exploring the world.
Of the five discovery skills, Dyer et al4 found experimentation to be the best differentiator between innovators and noninnovators. They identified three kinds of experimentation: trying out new experiences; taking apart products, processes, and ideas; and testing ideas through pilots and prototypes.4
By trying out new teaching methods in the safe HMI environment, scholars experience new roles firsthand and can assess more accurately how they feel about those roles and how they might fit in their own work environment. When working through case studies, faculty work with scholars to pull apart protocols, concepts, and initiatives from other industries, allowing the scholars to experience problems and solutions from different workplaces and contexts. One scholar noted that this process was particularly valuable:
The case-based lesson of learning in which we would take some example, discuss it, walk it through and then dissect it out—in terms of what worked and what could have been done better [and], what we did that was wrong—was really very helpful. That actually served as a model for what we did when I returned to my own institution.
Simultaneously, scholars are challenged to identify issues relevant to their institution or to their HMI problem or project and to consider ways to adapt new processes and solutions to their own contexts and/or endeavors. One scholar commented on the long-term effects that this experimenting at HMI had on his/her own work:
The Leaders program I did in 1999 … provided me with new insights, tools, and strategies which are used on a daily basis a decade later and which are especially useful for challenging, multidisciplinary “change” projects.
Learning about and examining theories about institutional change in their own and other fields helped scholars to develop the tools, confidence, and inspiration they needed to tackle educational change at their home institutions. Most survey respondents (89%) indicated that HMI was better than other CPD courses in “encouraging them to invent or design their own strategies” for innovation. For example, one alumni reported:
This program changed my view of my role in the health care system to think of medical education as a mechanism to impact patient care … this program equipped me with concepts and tools that I used to lead a network initiative to better train residents on central lines, interprofessionalism, and patient safety. As a result, four years after taking the program and leading this initiative, our CLAB [central-line-associated bacteremia] and complications rate are reduced significantly.
Effecting such long-lasting change is exactly what the HMI was designed to do. Scholars’ testimonials and survey results (85% of survey respondents thought the HMI was better than other CPD courses in leading to “a real change in their performance”) both attest to the HMI’s success at creating change agents.
Extending the Skills
To test whether HMI’s pedagogical approach could be replicated and extend its reach beyond the courses held annually, HMI sought to develop local cadres of innovators at institutions nationwide and internationally by giving priority to accepting individuals from institutions that sent scholars in previous years and whose leaders believe it is important to build a local group of change agents. To date, 157 institutions have sent five or more participants to HMI over the years; many have sent 20 or more. By developing a nucleus of faculty with a common understanding regarding education and innovation, there is a critical mass to challenge the status quo, champion significant change, and collectively create a long-lasting legacy.
Having people go to HMI has made all the difference in a very short period of time in our ability to move things forward, to function, and to really make things work better for students and faculty.
Advocates for reform in health care education call for innovative approaches to address increasingly significant and changing responsibilities for health care team members within an era of fewer financial resources.1–3,14 The challenge, then, is how—given this daunting context—to translate consistent and compelling recommendations for change into actionable strategies through education of faculty, administrators, and students. The retrospective findings from the HMI evaluation suggest that CPD programs can develop the five innovator’s skills and can enable health care educators to build capacity to successfully design and implement long-lasting organizational change.
Although the innovator’s DNA is a recent construct, other CPD program leaders may also be developing innovation capacity among health care educators. To provide evidence of a causal path, CPD program leaders and evaluators should develop a clearly delineated outcomes logic model15 with predicted, clear paths from CPD → innovator skills → implementation → implementation outcomes so as to guide the design of an experimental or quasi-experimental study with assessment measures for each step in the path.
In their study of the environments of teachers who support the creation of innovators, Wagner and Compton16 assert that the underlying culture and assumptions in research universities may constitute significant barriers to the production of innovators. Across multiple universities, they found that faculty who were viewed by their young innovator students as mentors were often marginalized by university leaders and administration or by other faculty because they did not conform to the content of an individual departmental domain, nor did they do the highly specialized types of research needed to merit promotion in the traditional tracks. Wagner and Compton’s findings remind us that reward systems—explicit and implicit—in academic health centers play a critical role in creating an environment that supports innovation.The educational academies movement is one example of the ongoing effort to overcome institutional barriers to change, as illustrated by this statement from the American Surgical Association Blue Ribbon Committee Report on Surgical Education14:
Surgical faculty members also need recognition and support for their efforts in residency education to facilitate development, implementation, and evaluation of innovative educational approaches. Also, such recognition and support is necessary for the much-needed changes in continuing education.
Richard Miller,17 president of the F.W. Olin College of Engineering where the curriculum is explicitly designed to create innovators, describes three distinct processes required for innovation: (1) creativity, generating original ideas, (2) inventiveness, taking original ideas and discovering insights that have value, and (3) innovation, having original ideas and insights that have value, then implementing them in ways that change the way people live and the way institutions function. As new CPD programs are created and existing programs reexamined, it seems increasingly critical that their leaders and faculty consider ways to build innovator’s skills which not only have value for the individual but also contribute to the advancement of innovation that is needed to improve the lives of those they serve.
Acknowledgments: The authors thank the Josiah Macy Jr. Foundation for the grant (HMS CHS M19366-101), which funded the program evaluation conducted between June 2010 and February 2011, as described in this document as well as for their initial grant, used to fund the development of the Harvard Macy Institute (HMI) and the 1994–2000 courses. They are very grateful to the HMI community of faculty and scholars for their participation in this study and their ongoing support of the HMI community.
Funding: Funding for this study came from the Josiah Macy Jr. Foundation (HMS CHS M19366-101).
Other disclosures: None.
Ethical approval: In July 2010, the Harvard Medical School institutional research board granted exempt status to this research, based on 45 CFR 46.101(b)(2).