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2.  Over the past 40 years the landscape of medical profession has witnessed massive changes in medical education and societal expectations from the profession.  The change from discipline-based conventional system of medical education to the integrated system bears promising outcomes but the journey could be a painful endeavour.  In this presentation I relate to our experience with the “Cynefin framework” for decision making and the use of multiple frames as a diagnostic and planning tool for change management while dealing with curricular change at Peshawar Medical College. 2

3.  Peshawar medical college (PMC) is a young medical college, established in 2005.  The vision and mission of the college is embedded in its slogan, “excellence in professional competence & ethical values”.  As part of its continuous endeavour to provide quality education to its graduates with excellence & compatibility with internationals standards, the college decided to introduce the integrated system of medical education in November 2009.  Central to the challenge was the issue of “acceptability” of the curricular change by the faculty, students and other stake holders.  To deal with this situation “Cynefin framework” for decision making by leaders and the paradigm of reframing were employed by the department of medical education and research. 3

4.  The traditional approach to leadership and decision making by the leaders is challenged by the ever-changing world of today with high degree of uncertainty and complexity  The mounting level of uncertainty in the environment, growing economic crisis, and quickly changing political arenas demand new leadership skills 4 Heifetz R, Grashow A, Lensky M. Leadership in a (permanent) crisis. Harvard Business Review 2009; 87 (7/8): 62-9

5.  “Cynefin framework” is a tool for decision making for the leaders and managers.  It draws its philosophy from the complexity science and focuses on sorting of issues/challenges faced by the leaders into five contexts  The advantage that it provides to its users is the ability to act in a contextually appropriate manner. 5 Snowden D J, Boome ME A. Leader’ s framework for decision making. Harvard Business Review 2007;2 (11):39-46

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7. Characteristics Simple context Complicated context Complex context Chaotic context Disorder context Ordered domain Clear cause- effect relationship Known-knowns The right answer The domain of best practice Ordered domain Clear cause –effect relationship Unknown-knowns Many options with at least one right answer The domain of experts Unordered domain Is there a right answer? Unknown- unknowns The domain of emergence Unordered domain Things that work Unknowables The domain of rapid response A combination of other contexts and the dominant context is not clear The leaders line of action Sense- Categorize- Respond (SCR) Anlyze-Sense- Respond (ASR) Probe-Sense Respond (PSR) Act- (Establish Order)- Sense –Respond (ASR) Break it into constituent parts and assign each to the aforementioned categories 7

8. 8 Homeostatic change Morphogenic change Moral change versus forced change Reforms versus revolution

9.  Fear of the unknown; feeling of insecurity borne out of loss of direction, clarity of ideas & uncertainty- a natural reaction  Fear of change in power structure of the organization; loosing power or change of the power epicenter;  Challenge posed to established practices, values, organizational culture, behaviours and expertise; previous experience being rendered in valid, lost years & the need to learn new skills, attitude and behaviours 9 KotterJP, Cohen DS. The heart of change : Real life stories of how people change their organizations.Boston:Harvard Business School Press, 2002.

10. Framing and reframing through the following frames  Structural  Human resource  Political and  Symbolic frames 10 Bolman LG, Deal TE. Reframing change in organizations. In : Reframing organizations- Artistry, choice and leadership. 4 th ed. San Francisco: Jossey-Bass2008: 373-96

11.  Complexity analysis of the problem was done through the “Cynefin framework”  Based on the outcome of the analysis further planning was based on framing the issues emerging in the context of acceptability through the structural, human resource, political and symbolic frames and then reframing them for contextual solutions.  Under each frame, reframing was specified as targeted activities concerning strategic and operational levels of management. 11

12. REFRAMING THE CHALLENGE OF ACCEPTABILITY OF THE CHANGE FRAMES ACCEPTABILITY ISSUES/CHALLENGES PLAN TO MEET THE CHALLENGE Structural frame Fear of the unknown; loss of clarity regarding direction, roles & responsibilities Clearly communicating new policies, roles and responsibilities of various people in the new system & realigning previous roles to the demands of the new system. A detailed plan of action available for the consumption of all concerned.  Study guides for the students  Facilitation guidelines for the faculty  Policy guidelines for the senior faculty members  Information booklets for the parents  Clear job descriptions Human resource frame Fear of experience lost to new ways (from expert to novice), incompetence, uncertainty and anxiety of job insecurity Participatory approach in planning, implementation and evaluation processes. Human resource development programmes for the new system for the existing faculty, training workshops, courses. Revised salary packages with incentives for those who provide support to the new system. Psychosocial support for the faculty through formal and informal individual communication. Customized communication for each faculty member especially those feeling apprehensive. Open all possible channels of communication, google groups, blogs, suggestion box for students and faculty. Parent –teacher meetings for communication with parents. Feedback channels for the students. Mentor mentee system for personal and professional development of the students & to support them in facing new challenges 12

13. REFRAMING THE CHALLENGE OF ACCEPTABILITY OF THE CHANGE FRAMES ACCEPTABILITY ISSUES/CHALLENGES PLAN TO MEET THE CHALLENGE Political frame Fear or assumptions about change in power structure, loss of power and control, conflict of interest Invite disagreement, open forums for dialogue, debate and expression of difference of opinion. Resolve conflicts through mutual understanding, negotiation. Communicate any change of power structure explicitly on these communication and debate forums. Be clear and sincere in accepting diverse opinions. Build coalition or support networks for the system. Open support by the leaders of PMC for those who support and own the system. Symbolic frame Fear of indenting the core values of the college. Failure to see the relevance with future plans and success of the college. Fear of loss identity of the college. Relate the change with the vision and mission of the college. Use established slogans and symbols to convey the new values. “excellence in professional competence and ethical values” can’t come without embracing new concepts and educational technologies. Revive the mission and vision of the college, communicate to the faculty (new and old), students and the parents. Celebrate the success of the launching of the system. Communicate the relevance with the future, what opportunities the new system offers for the coming times. Periodic meetings with the faculty and the student in an atmospheres of celebration to support the new system. 13

14.  According to the “Cynefin framework the problem of acceptability fell under the complex domain.  The activities under reframing were able to meet the specified targets.  The process of introduction of the integrated system of medical education at the institution was facilitated and supported through the plan 14

15.  In the changing field of medical education riddled with complex issues, traditional approaches to leadership with “one-size-fits-all” proposition are ineffective.  Medical educationists in leadership positions need to have tools for decision making and change management that allow them to embrace complexity and respond in a contextual manner with creativity, flexibility and vigilance  “Cynefin framework” & reframing through various organizational frames are tools worth keeping in one’s leadership and management inventories. 15

16.  Leaders of medical education have to develop leadership skills that integrate multiple perspectives and assimilate intricacies of complexity science in their decision making, planning and management styles. 16