Institutional Culture Change Research Articles

Diagnostic Safety: Needs Assessment and Informed Curriculum at an Academic Children's Hospital.

Diagnostic excellence is central to healthcare quality and safety. Prior literature identified a lack of psychological safety and time as barriers to diagnostic reasoning education. We performed a needs assessment to inform the development of diagnostic safety education. To evaluate existing educational programming and identify opportunities for content delivery, surveys were emailed to 155 interprofessional educational leaders and 627 clinicians at our hospital. Educational leaders and learners were invited to participate in focus groups to further explore beliefs, perceptions, and recommendations about diagnostic reasoning. The study team analyzed data using directed content analysis to identify themes. Of the 57 education leaders who responded to our survey, only 2 (5%) reported having formal training on diagnostic reasoning in their respective departments. The learner survey had a response rate of 47% (293/627). Learners expressed discomfort discussing diagnostic uncertainty and preferred case-based discussions and bedside learning as avenues for learning about the topic. Focus groups, including 7 educators and 16 learners, identified the following as necessary precursors to effective teaching about diagnostic safety: (1) faculty development, (2) institutional culture change, and (3) improved reporting of missed diagnoses. Participants preferred mandatory sessions integrated into existing educational programs. Our needs assessment identified a broad interest in education regarding medical diagnosis and potential barriers to implementation. Respondents highlighted the need to develop communication skills regarding diagnostic errors and uncertainty across professions and care areas. Study findings informed a pilot diagnostic reasoning curriculum for faculty and trainees.

Moving Toward Institutional Culture Change in Higher Education: An Exploration into Cross-functional Professional Learning Communities

Moving Toward Institutional Culture Change in Higher Education: An Exploration into Cross-functional Professional Learning Communities

A comprehensive, multifaceted strategy to increase pediatric donor heart utilization

BACKGROUNDMany hearts offered for pediatric heart transplantation (HT) are not placed. In 2016, we initiated a quality improvement endeavor to increase heart offer acceptance. This study assessed the effect of these interventions at our center. METHODSEvaluation of pre-/post-implementation cohorts (1/1/2008-12/31/2016 vs. 1/1/2017- 7/1/2023) comparing donor heart utilization. Six interventions were iterated over time to increase offer acceptance (“extended criteria”): ABO-incompatible transplant, ex vivo perfusion for distanced donors, 3-dimensional total cardiac volume (TCV) assessment, acceptance of Hepatitis-C or SARS-COV-2 infected donors, and institutional culture change favoring consideration of donors previously considered unacceptable (Public Health Service Risk, long CPR duration, etc.). Outcomes studied included annual HT volume, median waitlist duration, sequence number at acceptance, and post-transplant clinical outcomes. RESULTSFrom 1/2008–7/2023 annual transplant volume increased from 16/year to 25/year pre-/post-implementation. Three hundred-thirteen/389 (80%) listed patients were transplanted. Waitlist duration shortened post-implementation (P=0.01), as did the percentage of accepted heart offers utilizing at least one extended criterion (P<0.001). Institutional culture change and TCV assessment had the largest impact on donor heart utilization (P=0.04 &P<0.001). There was no difference in post-HT intubation or cardiovascular intensive care unit (CVICU) days (P= 0.05-0.9), though post-transplant hospitalization duration (P<0.001) increased. Post-transplant survival was unaffected by use of extended criteria hearts (P=0.3). CONCLUSIONSWe report increased donor heart offer acceptance resulting from a longitudinal, multi-faceted effort to increase organ offer utilization, with institutional culture change and TCV assessments having the greatest impact. Use of extended criteria hearts was not associated with inferior survival.

Establishing a plan to improve pediatric patient comfort during PIV insertions and blood specimen collection: a quality improvement effort.

Patient comfort during peripheral intravenous (PIV) insertion and specimen collection was increased. The authors extended the contingency plan implemented for PICC insertion to include PIV insertion and specimen collection. The authors met their goals by using quality improvement methodology. Prioritizing patient comfort often requires institutional culture change. Needle procedures can cause pain and distress, especially in pediatric patients.1 Retrospective data collected at a freestanding pediatric facility revealed that approximately 30% of pediatric patients were not demonstrating sufficient levels of comfort during peripheral intravenous (PIV) catheter insertion and specimen collection (lab draws) even after successful implementation of comfort measures by the vascular access team (VAT) in an adjacent procedure (eg peripherally inserted central catheter placement). The current quality improvement project was implemented to support adaptation and expansion of previous lessons learned to PIVs and lab draws specifically. The VAT used the Pediatric Sedation State Scale,2 a standardized assessment tool integrated into the electronic medical record, to assess procedural comfort during PIVs and lab draws from February 2021 through April 2023. A total of 24 134 patients aged 0 to 18 years were included in the data collection. Interventions were delivered concurrently and included (1) reeducation/ongoing support for implementation of the Comfort Promise3 measures, (2) the creation and implementation of advanced comfort options, and (3) culture change. The goal of the interventions was to improve the percentage of pediatric patients achieving adequate levels of comfort beginning at 68% in year 1 to 90% in year 2. From February 2021 to April 2023, the VAT team was able to improve procedural comfort scores from 68% to 90% of pediatric patients with adequate comfort for lab draws and/or PIV insertions. While standard comfort measures are a good first step in pain management during needle procedures, they are not sufficient for every pediatric patient. Nitrous, sedation, and the use of anxiolytics and analgesics can play an important role in reducing pain and anxiety during needle procedures and should be considered for patients not achieving adequate levels of comfort with standard comfort measures.

Establishing a Plan to Improve Pediatric Patient Comfort during PIV Insertions and Blood Specimen Collection: A Quality Improvement Effort

Highlights Patient comfort during peripheral intravenous (PIV) insertion and specimen collection was increased. The authors extended the contingency plan implemented for PICC insertion to include PIV insertion and specimen collection. The authors met their goals by using quality improvement methodology. Prioritizing patient comfort often requires institutional culture change. Abstract Background: Needle procedures can cause pain and distress, especially in pediatric patients.1 Retrospective data collected at a freestanding pediatric facility revealed that approximately 30% of pediatric patients were not demonstrating sufficient levels of comfort during peripheral intravenous (PIV) catheter insertion and specimen collection (lab draws) even after successful implementation of comfort measures by the vascular access team (VAT) in an adjacent procedure (i.e., peripherally inserted central catheter placement). The current quality improvement project was implemented to support adaptation and expansion of previous lessons learned to PIVs and lab draws specifically. Design and Methods: The VAT used the Pediatric Sedation State Scale,2 a standardized assessment tool integrated into the electronic medical record, to assess procedural comfort during PIVs and lab draws from February 2021 through April 2023. A total of 24,134 patients aged 0 to 18 years were included in the data collection. Interventions were delivered concurrently and included (1) reeducation/ongoing support for implementation of the Comfort Promise3 measures, (2) the creation and implementation of advanced comfort options, and (3) culture change. Aims and Objectives: The goal of the interventions was to improve the percentage of pediatric patients achieving adequate levels of comfort beginning at 68% in year 1 to 90% in year 2. Results: From February 2021 to April 2023, the VAT team was able to improve procedural comfort scores from 68% to 90% of pediatric patients with adequate comfort for lab draws and/or PIV insertions. Conclusions: While standard comfort measures are a good first step in pain management during needle procedures, they are not sufficient for every pediatric patient. Nitrous, sedation, and the use of anxiolytics and analgesics can play an important role in reducing pain and anxiety during needle procedures and should be considered for patients not achieving adequate levels of comfort with standard comfort measures.

Driving Diversity and Inclusion in Cancer Drug Development - Industry and Regulatory Perspectives, Current Practices, Opportunities, and Challenges.

In April 2022, the FDA issued draft guidance to help industry develop strategies to improve diversity in clinical trials. Historically, clinical trial sponsors have not systematically incorporated efforts to promote diversity, equity, and inclusion (DEI), particularly during the early design stages of clinical development plans and operational strategies. Unfortunately, a retrospective approach to DEI often results in clinical trial participants not being reflective of the diversity of patients intended to be treated with new therapies. A shift to prospective, intentional DEI strategies for clinical trials, including long-term engagement with diverse patients and communities throughout the development life cycle, is necessary to maximize the benefits and minimize the risks of new drugs and devices for all patients. Sponsors' current practices and opportunities for improving DEI address four major topics: institutional commitment, culture change, and governance; clinical development strategy; setting enrollment goals to ensure trial participant diversity; and development and implementation of the operational strategy. As DEI practices gain wider adoption in clinical trials, shared learning and collaboration among stakeholders on an ongoing and noncompetitive basis will lead to sustainable change. Prioritization of enrollment of diverse populations as an integral part of study start-up planning, clinical trial design, and recruitment capabilities will enhance the clinical development process for oncology therapies. Importantly, these efforts will help provide equitable access to clinical trials and innovative cancer therapies.

Strategies to Support Faculty Caregivers at U.S. Medical Schools.

To describe the policies, processes, and programs at U.S. medical schools to support faculty caregivers before and in response to the COVID-19 pandemic. In 2021, the Doris Duke Charitable Foundation and founding members of the COVID-19 Fund to Retain Clinical Scientists (FRCS) Collaborative launched and supported the COVID-19 FRCS program to recognize medical schools and their efforts to strengthen policies, processes, and programs supporting biomedical faculty with family caregiving responsibilities in the context of COVID-19-related impacts. The authors conducted a qualitative conceptual content analysis of the deidentified, open-ended responses submitted by institutions in their applications to the COVID-19 FRCS program and summarized the reported strategies using recurring patterns and common approaches. Fifty-four institutions applied to the COVID-19 FRCS program in 2021 and were included in this study. COVID-19-related impacts on biomedical faculty included stymied career progression and academic productivity, exacerbated career-caregiving time conflicts, adverse effects on family and personal well-being and mental health, increased financial hardships, and amplified faculty caregiver stigma. The described policies, processes, and programs to support faculty caregivers fell into 4 domains: support for dependent care, career and workplace flexibility, career development support, and institutional culture change to reduce stigma. COVID-19-related modifications spanned these domains with remote and flexible work manifesting as disruptive changes. Strategies to support women and underrepresented in medicine faculty, who bear a disproportionate burden of caregiving responsibilities, centered on career development support and institutional culture change. The projected durability of the enacted changes varied by institution and across strategies. The COVID-19 pandemic presents a disruptive opportunity to translate lessons learned into positive change to better support faculty caregivers, particularly women and underrepresented in medicine faculty. This study's findings provide a framework to guide sustainable change to support equity, diversity, and vitality in the academic biomedical workforce.

Exploring public health education's integration of critical race theories: A scoping review.

Public health has declared a commitment toward diversity as a whole, with a commitment toward addressing and dismantling racism being at the forefront. Although public health has admirably taken on this mission, and the foundational principles of public health align with social justice and health equity, public health as a discipline is vastly behind other fields in integrating and utilizing critical race theorizations. Of particular concern is the lack of critical race theorization within public health education materials. Public health education serves as a precursor to public health practice and situates topics and competencies that are essential to one's foundational public health knowledge and skillset, thus the use of strong theoretical groundings is critical in public health education. Therefore, to explore the current landscape of public health educational research that employs critical race theories, this study sought to conduct a scoping review investigating the current literature of public health pedagogical, instructional, and curricular efforts that utilize race and antiracist theorization principles as a means to administer public health education. More specifically, we sought to investigate how have faculty and instructors published their integration of race theorization in public health curriculum/instruction within the United States since 2011. We found 18 examples from peer-reviewed literature of curricular, pedagogical, or instructional practices and strategies that integrate critical theories of race, including contemplative pedagogy (n = 1), antiracism (n = 3), Public Health Critical Race praxis (n = 4), Critical Race (n = 5), critical service-learning/community engagement (n = 2), ethnic studies (n = 1), and intersectionality (n = 2). These articles present a wide breadth of innovative approaches to infusing critical race studies within public health higher education, ranging from individual assignments to course design and implementation to institutional culture change, thus demonstrating the multifaceted nature of critical race studies within micro-learning communities and macro-discipline practices. Identifying theoretically grounded, exemplary models and scholarly recommendations of pedagogical, instructional, and curricular practices provides readers the opportunity to borrow from successful practices and implement concepts of race, racism, antiracism, intersectionality, and more into their classrooms.

Confidence, Connection & Collaboration: Creating a Scalable Bias Reduction Improvement Coaching Train-the-Trainer Program to Mitigate Implicit Bias across a Medical Center

Problem: Academic medical centers need to mitigate the negative effects of implicit bias with approaches that are empirically-based, scalable, sustainable, and specific to departmental needs. Guided by Kotter’s Model of Change to create and sustain cultural change, we developed the Bias Reduction Improvement Coaching Program (BRIC), a two-year, train-the-trainer implicit bias coaching program designed to meet the increasing demand for bias training across a university medical center. Intervention: BRIC trained a cohort of faculty and staff as coaches during four quarterly training sessions in Year 1 that covered 1) the science of bias, 2) bias in selection and hiring, 3) bias in mentoring, and 4) bias in promotion, retention, and workplace culture. In Year 2, coaches attended two booster sessions and delivered at least two presentations. BRIC raises awareness of bias mitigation strategies in a scalable way by uniquely building capacity through department-level champions, providing programming that addresses the ‘local context,’ and setting a foundation for sustained institutional change. Context: In a U.S. academic medical center, 27 faculty and staff from 24 departments were trained as inaugural BRIC coaches. We assessed outcomes at multiple levels: BRIC coach outcomes (feedback on the training sessions; coach knowledge, attitudes, and skills), departmental-level outcomes (program attendee feedback, knowledge, and intentions) and institutional outcomes (activities to sustain change). Impact: After Year 1, coaches reported high satisfaction with BRIC and a statistically significant increase in self-efficacy in their abilities to recognize, mitigate, and teach about implicit bias. In Year 2, attendees at BRIC coach presentations reported an increase in bias mitigation knowledge, and the majority committed to taking follow-up action (e.g., taking an Implicit Association Test). Coaches also launched activities for sustaining change at the broader university and beyond. Lessons Learned: The BRIC Program indicates a high level of interest in receiving bias mitigation training, both among individuals who applied to be BRIC coaches and among presentation attendees. BRIC’s initial success supports future expansion. The model appears scalable and sustainable; future efforts will formalize the emerging community of practice around bias mitigation and measure elements of on-going institutional culture change.

Healthcare providers perceptions regarding the presence of Birth Companion during childbirth at a tertiary care hospital in India

BackgroundDespite an increase in institutional births and a fall in maternal mortality, the satisfaction of women with their birthing experience in public health institutions is low. Birth Companion (BC) is an important part of the Labour Room Quality Improvement Initiative introduced by the Government of India in 2017. Despite mandates, its implementation has been unsatisfactory. Little is known about the perception of healthcare providers about BC.MethodsWe conducted a facility-based, cross-sectional quantitative study with doctors and nurses in a tertiary care hospital in Delhi, India to gauge their awareness, perception and knowledge about BC. Following universal total population sampling, the participants were administered a questionnaire, which was completed by 96 of 115 serving doctors (response rate of 83%), and 55 of 105 serving nurses (response rate of 52%).ResultsMost (93%) healthcare providers were aware of the concept of BC, WHO’s recommendation (83%) and Government’s instructions (68%) on BC during labour. A woman’s mother was the BC of choice (70%) closely followed by her husband (69%). Ninety-five percent of providers agreed that the presence of a BC during labour will be beneficial, in providing emotional support, boosting the woman’s confidence, providing comfort measures, helping in the early initiation of breastfeeding, reducing post-partum depression, humanizing labour, reducing the need for analgesia and increasing chances of spontaneous vaginal births. Yet, support for the introduction of BC in their hospital was low due to institutional barriers like overcrowding, lack of privacy, hospital policy, risk of infection; privacy issues and costs.ConclusionsWidespread adoption of the concept of BC would require, besides directives, a buy-in by the providers, and action on their suggestions. These include greater funding for hospitals, creating physical partitions to ensure privacy, sensitization and training of health providers and BC, incentivizing hospitals and birthing women, formulation of guidelines on BC, standards setting and a change in institutional culture.

Accelerating Organizational Change to Build Mentorship Culture in Zambian Universities.

Strong cultures of mentorship and research remain underdeveloped at many African universities, threatening future knowledge generation essential for health and development on the continent. To address these challenges, a mentorship program was developed in 2018 at the University of Zambia with an aim to enhance the institutional culture of mentorship and to build institutional capacity through an innovative 'train the trainer' faculty development model. In this study, we documented perceptions of lived experiences related to mentorship culture by following trainers and trainees and their mentees over two years. We analyzed these perceptions to assess changes in institutional attributes regarding mentorship. We identified positive change in institutional culture towards mentorship, and this change appeared sustainable over time. However, a slight decrease in indicators for year two emphasizes the need for a continued culture of learning rather than assuming that one-off training will be sufficient to change culture.

Implementation of an integrated infectious disease and substance use disorder team for injection drug use-associated infections: a qualitative study

BackgroundHospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment intervention for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. We conducted a qualitative study to identify patient- and clinician-level perceived implementation barriers and facilitators to the SIRI team intervention.MethodsParticipants were patients with history of SIRIs (n = 7) and healthcare clinicians (n = 8) at one implementing hospital (Jackson Memorial Hospital). Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Research (CFIR). Interviews were transcribed, double coded, and categorized by study team members using CFIR constructs.ResultsImplementation barriers to the SIRI team intervention identified by participants included: (1) complexity of the SIRI team intervention; (2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; (3) clinician-level stigma and lack of knowledge around addiction and medications for opioid use disorder (OUD); and (4) concerns about underinvestment in the intervention. Implementation facilitators of the intervention included: (1) a non-judgmental, harm reduction-oriented approach; (2) the team’s advocacy for PWID as a means of institutional culture change; (3) provision of close post-hospital follow-up that is often inaccessible for PWID; (4) strong communication with patients and their hospital physicians; and (5) addressing diverse needs such as housing, insurance, and psychological wellbeing.ConclusionIntegration of infectious disease and SUD treatment is a promising approach to managing patients with SIRIs. Implementation success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction across multilevel (inner and outer) implementation contexts.

Physician Men Leaders in Emergency Medicine Bearing Witness to Gender-Based Discrimination

Approximately 60% of women physicians in emergency medicine (EM) experience gender-based discrimination (GBD). Women physicians are also more likely to experience GBD than men physicians, particularly from patients, other physicians, or nursing staff. To describe the responses of men who are academic department chairs in EM to GBD directed toward a woman colleague. This qualitative study was a secondary data analysis drawn from interviews of men EM academic department chairs at 18 sites who participated in a qualitative descriptive study between April 2020 and February 2021 on their perceptions of the influence of gender and leadership in academic medicine. Narrative data related to GBD were extracted and coded using conventional content analysis. Codes were clustered into themes and subthemes and summarized. Data were analyzed from November to December 2021. Semistructured interviews conducted via teleconferencing. Qualitative findings identifying experiences witnessing or learning about incidents of GBD against women colleagues, the impact of these observations, and personal or leadership actions taken in response to their observations. All 18 men participants (mean [SD] age, 52.2 [7.5] years; mean [SD] time as a department chair, 7.2 [5.1] years) discussed witnessing or learning about incidents of GBD against women colleagues. The participant narratives revealed 3 themes: emotional responses to GBD, actions they took to address GBD, and reasons for not taking action to address GBD. When witnessing GBD, participants felt anger, disbelief, guilt, and shame. To take action, they served as upstanders, confronted and reported discrimination, provided faculty development on GBD, or enforced "zero-tolerance" policies. At times they did not take action because they did not believe the GBD warranted a response, perceived a power differential or an unsupportive institutional culture, or sought self-preservation. In this qualitative study of men physician leaders, we found all participants reported feeling troubled by GBD against women colleagues and, if possible, took action to address the discrimination. At times they did not take action because of unsupportive workplace cultures. These findings suggest that institutional culture change that supports the interventions of upstanders and does not tolerate GBD is needed.

1984. Implementation of an integrated infectious disease and substance use disorder team for the treatment of severe injection-related infections

Abstract Background Hospitalizations for severe injection drug use-related infections (SIRIs) are characterized by high costs, frequent patient-directed discharge, and high readmission rates. Beyond the health system impacts, these admissions can be traumatizing to people who inject drugs (PWID), who often receive inadequate treatment for their substance use disorders (SUD). The Jackson SIRI team was developed as an integrated infectious disease/SUD treatment team for patients hospitalized at a public safety-net hospital in Miami, Florida in 2020. In order to facilitate implementation of this team, we conducted a qualitative study of patients and providers to identify barriers and facilitators to the team’s success. Methods Participants were patients with history of SIRIs (n=7) at the Jackson Memorial Hospital (JMH) and healthcare providers (HCPs) (n=8) at JMH. Semi-structured qualitative interviews were performed with a guide created using the Consolidated Framework for Implementation Science (CFIR). Interviews were transcribed and double coded by study team members using determinants adapted from the CFIR. Results Key barriers to SIRI team success included: 1) complexity of SIRI and SUD care requiring multidisciplinary teams and resources; 2) lack of resources for PWID experiencing homelessness, financial insecurity, and uninsured status; 3) stigma and lack of knowledge around addiction and medications for SUD; and 4) suspected understaffing and underfunding for the team. Facilitators of team success included: 1) holistic, integrated care being more efficient and effective than fragmented care; 2) the team’s advocacy for PWID as a means of institutional culture change; 3) provision of close post-hospital follow-up for an often-abandoned population; 4) non-judgmental, harm reduction-oriented approach; and 5) addressing diverse needs such as housing, insurance, and psychological wellbeing. Conclusion Integration of infectious disease and substance use disorder treatment is a promising approach to managing patients with SIRIs; however, success depends on institutional buy-in, holistic care beyond the medical domain, and an ethos rooted in harm reduction. Disclosures Susanne Doblecki-Lewis, MD, MSPH, Gilead Sciences: Grant/Research Support.

Multilevel impacts of a pediatric early warning system in resource-limited pediatric oncology hospitals.

BackgroundPediatric Early Warning Systems (PEWS) reduce clinical deterioration, improve interdisciplinary communication, and provide cost savings; however, little is known about how these impacts are achieved or related. This study evaluates the multi-level impacts of PEWS in resource-limited pediatric oncology centers.MethodsWe conducted 71 semi-structured interviews including physicians (45%), nurses (45%), and administrators (10%) from 5 resource-limited pediatric oncology centers in 4 Latin American countries. Interviews were conducted in Spanish, transcribed, and translated into English. A code book was developed using a priori and inductively derived codes. Transcripts were independently coded by 2 coders, achieving a kappa of 0.8-0.9. Thematic content analysis explored perceived impacts of PEWS at the level of the patient, clinician, healthcare team, and institution.ResultsPEWS improved the quality of attention for patients, reducing morbidity and mortality. Clinicians felt more knowledgeable, confident, and empowered providing patient care, resulting in greater job satisfaction. PEWS affected team dynamics by improving interdisciplinary (ward and intensive care unit) and interprofessional (physicians and nurses) relationships and communication. This ultimately led to institutional culture change with emphasis on patient safety, collaboration with other centers, and receipt of institutional awards. Together, these impacts led to hospital-wide support of ongoing PEWS use.ConclusionsIn resource-limited hospitals, PEWS use results in multi-level positive impacts on patients, clinicians, teams, and institutions, creating a feedback loop that further supports ongoing PEWS use. These findings can guide advocacy for PEWS to various stakeholders, improve PEWS effectiveness, and inform assessment of other interventions to improve childhood cancer outcomes.

Student partnership to achieve cultural change

This case study offers reflections on a student-led collaboration between the university and its student representative body (the Students’ Union) and outlines the successes and challenges of partnership to address institutional cultural change. The project was set up to improve students’ experiences and raise awareness of the existence of differential outcomes between Black, Asian, or minority ethnic (BAME) and white students and to promote strategies to build meaningful relationships through the development of internal and external networks. It was led by 11 BAME student ambassadors who developed and delivered campaigns and events for students and who linked with university staff and the Students’ Union to represent students’ views on ways to achieve positive change on campus. Partnership working was essential to enable the student ambassadors to develop trust, make their own changes, and influence key decision makers across the University.

A Grassroots Approach to Addressing the MCH Workforce Crisis.

Following predictions of a dramatic drop in the developmental-behavioral healthcare workforce by 2023 due to retirement and/or burnout, much has been written about ways to replenish or sustain needed personnel. To date, we continue to have a crisis of not enough new clinicians being attracted to the field to replenish the third of the workforce that is expected to retire. Recent concerns about increased clinician mental health problems and burnout in the wake of COVID-19 and other societal stressors add further complexity and urgency. This crisis will not be solved solely by a top-down focus on intensive graduate training or marketing to newly licensed professionals. Through the lived experience of three fellows from the Leadership Education in Neurodevelopmental and related Disabilities (LEND) program, this paper offers a “grassroots” approach to supporting people with disabilities (PWD) to weather this rebuilding period by increasing (a) their material wealth through entrepreneurship and (b) capacities for self-determination through thoughtful mentorship and considered changes in institutional culture.

Institutional Culture Change

The purpose of the paper is to explore the architecture of the institutional culture with the aim of proposing a programmatic template to use to implement culture change initiatives in the higher education (HE) sector in South Africa. The need for institutional culture change has been flagged in numerous studies as a barrier in the implementation of substantive and qualitative transformation. Through document analysis, this paper argues that the problem in implementing institutional culture change interventions aligned with the humanising mission of the sector is related to the failure to adopt a social inclusion approach that is based on a systems thinking paradigm. The paradigm is a holistic analysis of a system with the purpose of identifying elements of that system, which this research manifests and explicates. The findings of the research show that changing institutional culture is inextricably linked to the objectives of transformation. Second, the article highlights the significance of adopting the social inclusion framework, including understanding the politics and practices of social inclusion.

Signaling hostility: The relationship between witnessing weight‐based discrimination in medical school and medical student well‐being

AbstractEnvironments that are hostile to one or more marginalized groups are known to have a negative effect on the mental health and well‐being of both targets and observers. Anti‐fat attitudes have been well documented in medical education, including the use of derogatory humor and discriminatory treatment toward higher‐weight patients. However, to date, it is not known what effect observing weight stigma and discrimination during medical school has on medical students’ psychological health and wellbeing, sense of belonging, and medical school burnout. The present study surveyed a total of 3994 students enrolled across 49 US medical schools at the start of their first year and at the end of their fourth year. Participants reported the frequency with which they had observed stigmatizing and discriminatory behaviors targeted at both higher‐weight patients and higher‐weight students during their four years of medical school. Observed weight stigma was prevalent, and was associated with worse psychological and general health, reduced medical school belonging and increased medical school burnout. The indirect effects of observed weight stigma on medical school burnout, via belonging, psychological health, and general health, were statistically significant in the sample as a whole, but were more pronounced in higher‐weight students. This effect may be explained, in part, by the relationship between observed stigma and medical school belonging. Higher levels of observed stigma were associated with reduced feelings of belonging in higher‐weight but not normative‐weight students. Top‐down institutional culture change is needed to rectify this situation, which is detrimental to both students and patients.

Evolution of Palliative Care in the Department of Veterans Affairs: Lessons from an Integrated Health Care Model.

Palliative care (PC) is beneficial, however, in many settings it is under-resourced and unable to consistently meet the needs of patients and their families. A lack of national health policy support for PC contributes to underutilization and the low value care experienced by many patients with serious illness at the end of life. Through a series of transformative health care structure and process improvements including developing robust initiatives and promoting institutional culture change, the Department of Veterans Affairs (VA) has significantly improved the quality of PC among veterans. VA's strategic simultaneous top-down and bottom-up approach to develop programs, policies, and initiatives provides important perspectives and deserves attention toward advancing PC in the broader U.S. health care system. Although opportunities for improvement exist, the comprehensive framework within VA should help inform the future of program development and serve as a model for integrated and accountable care organizations to emulate.