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The Lessons and The Legacy of the Pew Health Policy Program (1997)

Chapter: Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future

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Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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Part IV.
Summarizing the Legacy: Some Conclusions and Thousand for the Future

The best investment around is the professional school.

—Peter Drucker

Bottom line: there is still a real need. I do not think the job is done.

—Hal Luft

The greatest thing about the Pew program is that it got people excited.... Wow, we can change the world!

—Linda Simoni-Wastila

This fourth and final section of the report attempts to draw the many loose threads together. Based on archival work, the external evaluations, the 25 interviews and narrative accounts, the roundtable discussions and focus groups, and the authors' observations, the Pew Health Policy Program (PHPP) evolved from a unique, ambiguous idea to a highly successful, highly sought after, and well-respected academic program. The demographics are mesmerizing: hundreds of graduates have been placed into a wide variety of health policy jobs and they are now university professors, researchers, consultants, federal and state policy makers, and health care managers.

The Pew Health Policy Program evolved from a unique, ambiguous idea to a highly successful, highly sought after, and well-respected academic program.

Some questions remain. From a strategic standpoint, what are the elements of successful programs? How are the collective accomplishments summarized? What lessons have been learned about niche educational programs in health policy? Where do we go from here?

Part four of this report addresses these questions in four sections. The first section develops (with the aid of an analytic framework) strategic guidelines to help foundations and

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

academic institutions to implement niche educational programs. The second section highlights the lessons for other academic institutions learned from the Pew experience. The third section summarizes (in a nonscientific way) impressions of the collective accomplishments and program impacts. To accomplish these three final tasks, the focus is shifted away from the voice of the participants to a more conceptual plane that makes sense of the Pew legacy as a ''lived experience."

As Hal Luft, Stuart Altman, Marion Ein Lewin, and others have said, we have learned how to do this, and this work needs to continue. Therefore, it is appropriate for this section to consider the future not only in terms of knowledge creation and vision but also the degree of future participation in policy making and policy training. It is unlikely that market forces will mobilize the loosely coupled community of Pew scholars into an active network. There is a need for a few leaders in the group to create a strong organization. The fourth, and final section concludes by offering the Pew fellows thoughts about a path for the future.

A STRATEGIC FRAMEWORK FOR ANALYZING THE PHPP EXPERIENCE: BASIC AND INTEGRATIVE ELEMENTS

This section analyzes the PHPP from a strategic standpoint by employing a analytic framework developed by Heskett.1 According to Heskett (1986) there are four basic elements for success in implementing any service. They are targeting markets, well-defined service concepts, focused operating strategies, and well-designed service delivery systems. Heskett also argues that the four basic elements mentioned above are mediated by three integrative elements: positioning, leveraging, and integrating the operating strategy with the service delivery system. In fact, each of the PHPP sites spent the last dozen or so years honing health policy programs around these basic and integrative elements.

Each of the sites assembled its programs around the four basic elements for strategic success (Heskett, 1986). Sites targeted internal (faculty) and external (fellows) "market" segments and focused on understanding their needs. Each site also carefully crafted a distinct educational service concept in terms of the results that they could produce for fellows and faculty. A third basic element during implementation was developing a focused operations strategy, and the fourth element was designing a system (pedagogy and methodology) for providing educational services.

1  

This section is based on the framework developed by James Heskett (1986) in his book Managing in the Service Economy.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

Each program eventually developed a distinct market niche in health policy by positioning itself to serve faculty, students, and the health policy world. Irrespective of how programs position their educational concept, they must leverage their activities so that the education is valued by the fellows. This was especially important for the midcareer and on-job/on-campus students. Finally, all of the programs in varying degrees, had to integrate and coordinate their operating strategies with their other educational programs (delivery systems) to insure a high quality education at reasonable costs, an engaged faculty, and internal consistency (Heskett, 1986). These ideas are portrayed in Figure 2.

Figure 2.

Developing Niche Education Programs: Basic and Integrative Elements

Adapted from Heskett, 1986

DEVELOPING STRATEGIC PROGRAM VISIONS: BASIC ELEMENTS

Recruiting Faculty and Fellows: Examples of internal and External Targeting

To launch an educational program, there is a need to do internal faculty recruitment and external fellow recruitment. There is a synergy between the two types of recruitment. To have a successful program, a strong and committed core faculty had to be enlisted and deployed. To attract a strong faculty, excellent students are needed.

Involving faculty members in new activities is difficult, requiring resources and resourcefulness. Two examples illustrate the idea. At the University of Michigan program, they found

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

that running an off-site weekend program required obtaining an "up-front" commitment of faculty willing to teach adult learners on Saturdays and Sundays for 5 months of the year. Traditional ways of hiring faculty did not work, because a new breed of faculty member was needed. According to Richardson (1990), "the faculty selected to teach this group of adult learners" had to be carefully screened and oriented because many Pew fellows were experts in their work domains. Over time Michigan learned how to develop and deploy an outstanding faculty.

At the University of California at San Francisco (UCSF), for example, the problem of engaging the faculty required "selling them" on the benefits of working with postdoctoral fellows. When the program began attracting exceptional Pew fellows, a committed faculty quickly surfaced. RAND/University of California at Los Angeles (UCLA) was able to build on the strengths of the faculty at each school to create a singularly rich training program.

The faculty selected to teach this group of adult learners had to be carefully screened and oriented because many Pew follows were experts in their work domains. PHPP averaged students with 12 to 14 years of work experience before they came to the Pew program.

Targeting excellent fellows to keep the faculty interested and involved was not unique to UCSF but occurred at every site. There is strong evidence that all of the program sites managed to attract high-quality fellows from a strong applicant pool. Throughout the program, the outside evaluators found the quality of the fellows to be "very strong"; moreover, there were noticeable improvements in the quality of fellows from 1982 to 1985, 1985 to 1989, and 1989 to 1994. PHPP averaged students with 12 to 14 years of work experience before they came to the Pew program. The postdoctoral fellows were PhDs, and clinicians. The predoctoral fellows often had Master's degrees or professional graduate degrees from excellent schools.

In doctoral and postdoctoral programs, the attrition rates are surprisingly high (Bowen and Rudenstine, 1992). PHPP hypothesized that attrition may be related to the ability to recruit high-quality students. Therefore, the Pew program focused on "quality students" along two dimensions: (1) finding the best and brightest candidates and (2) finding people motivated to complete these challenging programs.

Recruitment of high-quality, highly motivated fellows was not the only recruitment characteristic. Each program also had to discover ways to single out groups of applicants (i.e., student segments) with common characteristics whose educational needs could best be met by a particular program in terms of the results they could deliver. So, in recruiting fellows, each program had to learn how to screen for fellows motivated and capable of completing the degree and who fit well with the educational services that the program could deliver.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

Discovering ways to single out segments of applicants was not a trivial problem for a niche program in health policy. The Michigan program, for example, was a nonresidential doctoral program in health policy for working people. This meant locating prospective fellows who wanted to pursue a full-time doctoral program without giving up their full-time professional lives.

To increase the chances of locating highly qualified fellows, schools need to select from a large applicant pool. Recruiting from a national (as opposed to a local) market yields a larger pool. Michigan learned that its program had great appeal to high-profile, midcareer professionals from government and health care management, which offered a large, national segment to draw from. Recruiting Michigan fellows from this pool, however, was tricky because Michigan fellows had to be good at both work and school. To complete a doctoral degree, Michigan had to identify fellows who could master the craft of being a good student. By and large, great leaders are not great students; moreover, older students do not do well on standardized tests. To insure that fellows who were selected would complete the program, Michigan used college grades, past work accomplishments, and Graduate Record Examination (GRE) scores as criteria for final selection.

To increase the chances of locating highly qualified fellows, schools need to select from a large applicant pool. Recruiting from a national (as opposed to a local) market yields a larger pool.

Each of the programs found different ways to group applicants into segments with common characteristics. At first, Boston University (BU)/Brandeis sought people who had had some governmental or health care management experience and who wanted advanced training in health policy. At BU, the Center for Industry and Health Care aimed at increasing the involvement of the business community in health policy by establishing corporate coalitions, so they targeted students who were planning careers in business and public service. Over time, Brandeis singled out people who were interested in issues of social justice for vulnerable populations-violence, people with AIDS, chronic disease populations, veterans, and so on. The UCSF program targeted a high-quality national pool, consisting of a mix of applicants who wanted advanced training in research: MDs with specialties in primary care and preventive medicine and PhDs (in social science and other areas) from academia.

An Evolving Educational Service Concept

To recruit bright and motivated fellows who are willing to leave their jobs and careers to go back to school and to

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

attract a dedicated faculty willing to allocate their time and attention, an educational service concept must be defined. This educational concept must be defined not as offering a degree or a high quality educational experience but in terms of opportunities and potential advantages for the fellows and the faculty. At the outset of a program, it is rare to have clarity in an educational concept; concepts evolve.

The program had a commitment to excellence and ability to take corrective action when the external program evaluations uncovered weaknesses.

In 1981, the staff at the Pew Charitable Trusts believed that there was a lack of depth and breadth in health policy research, analysis, and management, and they believed that multidisciplinary educational concepts might address this problem. Each of the sites offered variations on the traditional educational concept: providing a high-quality educational experience for students. One key result area, implicitly promised by the Pew Program was in an area in which graduate education fails to achieve, academic survival and success.

Over time, the programs sharpened their definitions of these concepts. In part, this occurred as a result of the programs, commitment to excellence and ability to take corrective action when the external program evaluations uncovered weaknesses. Defining the concept became an evolving process, in which programs learned the results that can be achieved and they adapted the current concept in that direction.

UCSF initially offered three types of 2-year fellowships: predoctoral, postdoctoral, and management. The predoctoral and management programs, although highly successful, were discontinued so that resources could be concentrated on developing a strong postdoctoral program. The educational concept was a multidisciplinary postdoctoral health policy program in which fellows worked with faculty on research projects. The faculty would commit to an active involvement with fellows as mentors and colleagues. Faculty would participate in annual fellow reviews and mentorship meetings.

The BU/Brandeis program initially contained two elements: a Pew scholars program and a Pew fellows program. The Scholars Program was an on-campus, post-master's, multidisciplinary accelerated doctoral program which aimed at reducing the time, cost, and incompletion rates to produce educated individuals effective in the health policy system. The Pew fellows program aimed at mid-level and upper-level managers and trained them in health care management and cost-containment strategies.

Michigan offered a unique, nonresidential 3-year doctoral program in health policy. The central educational con-

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

cept was that fellows could get their doctorates while keeping their jobs. The OJ/OC doctoral program provided 20 4-day sessions and two 4-week sessions. Upon completion of the program, fellows received a doctor of public health degree.

Each of the program developed a strong core curriculum that taught students to appreciate and synthesize the clinical, sociological, political, economic, and behavioral implications of the policy process.

In 1982, a joint venture between RAND/UCLA offered a 3-year interdisciplinary program in which fellows could obtain a PhD in policy analysis at RAND or a PhD in several different areas, such as public health and epidemiology at UCLA. The program also had a 10-session lecture discussion series to introduce medical students to policy issues and a 1-year nondegree policy career development program.2

A Focused Operating Strategy

Heskett (1986) argues that that to deliver on the promises implicit in the educational concept (while achieving the internal operating goals) a focused operating strategy is needed. This especially makes sense for an educational program since faculty and other resources are so scarce. So, to develop into a high quality educational services program, the PHPP leadership had to concentrate its attention in a few strategic areas, which included:

  1. developing a strong curriculum with a well-integrated learning sequence,

  2. the deployment of faculty,

  3. the creation of a small "service-oriented" organization, and

  4. the control of costs.

Developing a Strong Curriculum That Ensures Academic Success and Survival

The multidisciplinary nature of the curriculum was mentioned throughout the interviews and evaluations as one of the greatest strengths of PHPP. In each of the programs, the social sciences, economics and clinical "disciplines" began to be seen as "tools" to help policy makers solve problems. Each of the programs developed a strong core curriculum that taught students to appreciate and synthesize the clinical, sociological, political, economic, and behavioral implications of the policy process. (The actual curriculums are in Appendix B.)

For example, one of the major strengths of the Brandeis program was its broad multidisciplinary approach. The doctoral program required course work in the basic social sci-

2  

 By 1991, it was decided that three educational concepts should be maintained: postdoctoral education in a policy-rich environment, an accelerated doctoral program, and a doctoral program for people with full time jobs.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

ences, statistics, research methods, and policy analysis and advanced course work in health policy (Issues in Health Policy; Health Care Organization and Politics; Social, Ethical, and Legal Issues; and Health Economics). At least one course in special populations was also required.

However, to ensure academic survival and success in postdoctoral work, midcareer programs, and the accelerated doctoral program, new mechanisms were needed. The dissertation seminars at BU/Brandeis and Michigan became a pedagogical mechanism not only to help students structure and manage the dissertation process early on but also to provide the psychological support to build and connect the fellows into a committed group of mature scholars. An innovative mechanism was needed to get students to start thinking about a dissertation on the first day of the program. The dissertation seminar also became an opportunity to integrate the multidisciplinary curriculum.

The dissertation seminars at BU/Brandeis and Michigan became a pedagogical mechanism not only to help students structure and manage the dissertation process early on but also to provide the psychological support to build and connect the fellows into a committed group of mature scholars.

The promise of survival and success in a postdoctoral program also required a strong core curriculum. In addition to developing a strong health policy curriculum, UCSF developed a weekly health policy seminar, writing seminar, and journal club to sharpen the fellows' communication skills. These seminars became mechanisms for bringing fellows closer to researchers and policy makers, while providing psychological support and assisting in their "socialization" in health policy.

To help ensure academic survival, RAND/UCLA employed an innovative strategy that included an early dissertation focus with an research apprenticeship model. Not only did this innovation get students to experience real research and to develop professional relationships with faculty; these projects often turned into dissertations.

Faculty Deployment

To meet the fellows' expectations for an exceptional education, there was a need to provide adequate contact with faculty. At UCSF the operating strategy focused on a highly structured learning sequence and a model of mentoring. The mentoring at UCSF worked well. The model required each student to work with two faculty members in an apprenticeship model. Pew, through its habit of systematic program evaluations "prodded," the programs to develop more structure.

All of the Pew programs compensated the faculty for their contribution to the program in one of two ways:

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

(1) remuneration for time spent or (2) the opportunity to be a mentor for and collaborate with some excellent fellows. Although money alone does not motivate faculty, asking faculty to teach additional courses in health policy without pay ''can be difficult."

At UCSF, the model was very faculty intensive, with one or two faculty mentors assigned to a fellow. Hal Luft said that getting fellows involved with faculty research did work. Faculty liked working with Pew fellows, who were seen as good colleagues. Although faculty were not compensated with salary, the faculty were motivated by intrinsic rewards, such as the value of working with a good research assistant.

Changing Behavior Patterns via Service-Oriented Culture

The organization of most graduate schools offering predoctoral and postdoctoral education is a hierarchical, loosely coupled set of rituals and routine activities that more or less accomplish the task of enrollment management. The premise of most graduate programs is that given enough time, students will find their way around. They will link up with faculty, select the right courses, and connect with interesting and important research. The process is haphazard, and not student centered.

Faculty liked working with Pew follows, who were seen as good colleagues.

For the PHPP to work, people had to go out of their way to help students connect with faculty and offer greater flexibility when problems arose. Not every program succeeded in creating a service oriented culture; in fact, fellows complained about the need for more attention. But every program did create a small, effective staff usually involving one faculty member as program director, one or two key faculty, and one or two support staff to serve faculty and fellow needs. Program champions also emerged at each site.

Cost-Effectiveness

Although every program had to control costs, because of its unique service concept and national targets, Michigan had to focus on controlling costs. Since Michigan chose to target fellows from a national (not local) pool, the program managers had to control (1) travel costs, (2) communication costs, and (3) the massive investment in regular and adjunct faculty, all within the regular tuition structure. Therefore, the Michigan program not only managed costs but also became cost effective.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

Developing an Educational Program into a Well-Designed Delivery System

To offer an educational program, facilities must be designed to work well with the operating strategy. Programs must consider the important characteristics of the educational program as a service process. In fact, the development of an educational service delivery system was an important feature of each program's evolution. Explicit consideration had to be given to the role of key people, physical layout, and changing procedures.

Role of Key People

To deliver on the strategy of a service-oriented culture, each of the programs needed an incredibly dedicated program staff to serve faculty, students and program leadership. At RAND/UCLA, Kate Korman was cited as "an indispensable linchpin with respect to tying together diverse interests and activities." Throughout the interviews, Marion Ein Lewin, Steve Crane, Ted Benjamin, and David Perlman were all mentioned as being extraordinarily supportive.

Physical Layout

Every program created a small, effective staff usually involving one faculty member as program director, one or two key faculty, and one or two support staff to serve faculty and fellow needs. Program champions also emerged at each site.

Placement of people in offices (or the lack of office space) affects people in a number of ways. Physical layouts are an indicator of social distance and membership (Schein, 1985). The allocation of space (crowding students into rooms, size of the office, and quality of the furniture) symbolizes the rank of the people and affects their feelings of inclusion. Finally, organizational research has shown that the probability of weekly interactions drops to zero when people are more than 40 meters apart. Being on different floors (or buildings) is like being in different cities.

Each of the programs was challenged by the physical locations of the fellows, especially in relation to faculty. Some programs, such as Brandeis, were never able to offer their fellows office space, which undermined communication. To compensate, Brandeis provided weekly dissertation seminars and biweekly colloquia which were opportunities for concerted group action. In a bid to promote communication among off-site participants, Michigan used electronic communication.

UCSF found that to the extent that fellows were located off-site, interaction with faculty and other fellows was hindered. The situation improved when office space became avail-

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

able. They found that when they brought the fellows into office space with the faculty, mentoring relationships improved.

Changing Rules and Procedures

Although there was a clear need for many more people broadly trained in health policy, each program had to focus its attention on what it could do differently from other graduate programs in health services.

At Michigan, they discovered that the OJ/OC weekend mode resulted in the accumulation of many incompletes because of the working students' inability to complete term papers. Over time, these incompletes became obstacles to completing the dissertations. The remedy was the creation of new procedures aimed at discouraging major papers due at the end of a course. The procedures encouraged the faculty to assign deliverables over the terms rather than a major paper at the end of the term. As a result of those procedures, the rate of incompletes dropped. Incompletes were only given if a serious personal problem (such as a death in the family) had occurred. The procedures helped to reduce the risk of low completion rates.

To decrease feelings of elitism and to increase integration among Pew and non-Pew students, BU/Brandeis changed the rules to allow any student into the dissertation seminars. To help fellows complete the program in 2 years, Brandeis changed its procedures to allow Pew fellows to take their qualifying examinations in the first year.

At UCSF, formal procedures were developed to improve faculty-fellow interactions and mentoring. Incoming fellows received a detailed orientation to the faculty. Fellows had scheduled meetings with their primary research advisers. Finally, guidelines listing goals and expectations of the faculty mentors and fellows were developed.

DEVELOPING STRATEGIC PROGRAM VISIONS: INTEGRATIVE ELEMENTS

Positioning Each Program

Positioning in education means identifying academic needs that no one is serving. Before each site could position itself it needed a deeper understanding of: (1) what other health services research doctoral programs were offering, (2) the needs of potential employers in the policy world and (3) how to serve the educational needs of the students. Although there was a clear need for many more people broadly trained in health policy, each program had to focus its attention on what it could do differently from other graduate programs in health services. Most programs focused on teaching policy analysis and advanced research skills from a single perspec-

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

Traditional doctoral education takes a long time to complete, and relatively few survive. Doctoral education is plagued by low completion rates, often 50 to 60 percent in the social sciences and those who complete all but the dissertation have an 80 percent chance of obtaining the PhD. The doctoral completion rate for PHPP as of 1996 was 66 percent.

tive-public policy, public health, political science, health administration, or health economics. Few programs positioned themselves where health policy and advanced theoretical and research training intersect. They also had to find ways to customize the training and education to enhance the value-added per fellow.

If the PHPPs were to differentiate and distinguish themselves, they also had to understand the new world of health policy. New policy units had emerged in the 1980s, such as the Physician Payment Review Commission (PPRC). These new policy centers needed well-educated people with strong analytic skills and a deep understanding of the health care context. The new world needed a mix of analytical and methodological skills with a context-specific policy knowledge base. The context-specific (as opposed to context-free) education set the Pew graduates apart from graduates of other programs.

The Michigan program positioned itself to appeal to high quality people who never could have obtained a PhD because traditional programs require leaving a job for at least 2 or 3 years.

To understand how PHPP carved health policy niches, one must consider what graduate education is all about. Traditional doctoral education takes a long time to complete, and relatively few survive. In general, doctoral education is plagued by low completion rates, often 50 to 60 percent in the social sciences and those who complete all but the dissertation have an 80 percent chance of obtaining the PhD. The median time between entry to graduate school and being awarded the PhD is 6.7 years (Bowen and Rudenstine, 1992).

Why does this occur? There is no theory about student survival rates, but several plausible hypotheses are offered. First, doctoral education has very high opportunity costs for the average student. In addition to doctoral expenses, students lose the money they would have earned had they not been a student. Many students work at part-time (and some at full-time) jobs throughout their education. Many keep their job responsibilities while they are students. Others take odd jobs, work as consultants, and so forth.

A second hypothesis is that other aspects of a student's life begins to take over after 2 or 3 years. For example, once the course work is completed, many full-time doctoral (having completed all but the dissertation) students take on full-time jobs. They assume that since they have managed to complete the examinations and dozens of courses, they can write their dissertations around the edges of their lives. Many find that time passes as relentlessly as a Boeing 747; 5 years have gone by and they have written a few pages since

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

they left the program. Given the high costs of the education when the student is ''All But Dissertation," the value of finishing the degree often depends on the current reputation of the school in the national competitive arena.

A third hypothesis about why it is hard to finish has to do with the very nature of academia and beliefs about the amount of time people need to master the knowledge and to think about opportunities to make contributions. Traditional predoctoral education allows students to limit their commitment to the sequential completion of required tasks. First, take courses and other requirements, next take general examinations, then one can think about the dissertation proposal. The learning sequence plays out as rigid rules.

Throughout the course work, the responsible faculty member distracts students (in a positive way) by suggesting another course, more reading, rival theories, other perspectives, and so on. The underlying assumption is that learning what we know and what we don't know requires lengthy time periods.

Finally, the core doctoral faculty take a passive rather than an active stance with students. They wait for students to "find" them; access to faculty regarding student's research interests is often sporadic, haphazard, and peripheral to the doctoral "program." Some programs talk about mentoring, but few have developed formal mentoring components, such as UCSF (see Appendix C).

Table 5 reveals some of the ways that PHPP positioned its predoctoral education. The positioning required a focused operating strategy on unlearning old ways of doing things and organizing for innovation. For PHPP to succeed, it had to change the nature of academia and break some of the rules of traditional doctoral education. The individual programs not only had to promise a high probability of academic success and survival, but to do so in an accelerated time period. There would be full tuition scholarships; in addition, the opportunity costs would be offset by allocating stipends to doctoral fellows. In addition to a standardized general curriculum, there would be an early dissertation and research focus and flexibility with respect to requirements so as to allow the development of highly individualized learning plans. A "high-touch" philosophy would be implemented by encouraging the faculty to take a more active stance, and in most, if not all, cases faculty mentors would emerge.

For PHPP to succeed, a national identity had to be created. PHPP created a kind of "membership in a club" relationship between the fellows and the national office. The value of an individual to the policy world would be augmented by one's status as a Pew fellow.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

Table 5. Positioning of the Pew Health Policy Program Versus Traditional Doctoral Programs

Traditional Predoctoral Approach

PHPP Approach

• Lengthy time to completion

• Moderate to low survival rates

• High opportunity costs

• Some outside income required

• Sequential attention to tasks

• Rigidity to rules

• Passive faculty stance

• Informal access to faculty

• Dependence on school reputation

• Accelerated time to completion

• Higher survival rates

• Moderate opportunity costs

• Fellowship includes stipends

• Early dissertation/research focus

• Flexibility

• More active faculty stance

• Formal mentoring requirements

• Development of national identity

Leveraging Program Costs Over the Value of the Program to the Follows

If niche programs are to be institutionalized, the educational service concept must be positioned in a way that a margin (student tuition minus relevant unit variable costs) covers faculty and staff costs and future program costs. For this to happen, niche programs must leverage program value over cost. That means that educational service concepts and operating strategies must be developed in ways that strongly appeal to faculty and fellows in the program, while keeping costs to provide the program reasonable (Heskett, 1986). Each of the programs leveraged the program in one of four ways: (1) building on a core competency, (2) adding value via network effects, (3) combining standard curriculum with customized elements, and (4) deep involvement of fellows.

Building on Core Competencies

Each of the programs identified its core competencies and built the program on the distinguishing competencies. These competencies were not always obvious to the programs at first. Some programs tried to develop new strengths, but over time they came back to those things that they did best.

UCSF built its program on the strength of its medical school, nursing school, and Institute for Health Policy Studies. The faculty from those places believed that research was a team effort and they also believed in the learning by doing model. All of these strengths came together in the UCSF Pew program, which was designed as a postdoctoral program for advanced research studies that would team up MDs with PhDs in social science. Although there were no preexisting

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

health policy courses in which fellows could enroll, with Pew support they were able to leverage the faculty to develop some excellent courses.

At RAND/UCLA, leverage came from building on the workshop model, which it had used in the graduate school. When the Pew program began, it modified workshops or seminars on broad policy domains with a set of modules. Policy exercises were required which made the fellows think analytically about a contemporary health policy problem via a policy memo or class presentation. The RAND program, whose predoctoral programs had a high completion rate, created an on-the-job component in which fellows spent half their time working with faculty on real research projects. In many cases these projects resulted in a completed dissertation.

Michigan also built its program from a core competency. It had developed an innovation nearly 30 years ago—a midcareer, weekend program in which everyone took the same courses. PHPP built on years of experimenting and improving the OJ/OC educational concept.

For PHPP to succeed, a national identity had to be created. PHPP created a kind of "membership in a club" relationship between the fellows and the national office.

Leverage at Brandeis came from two places. First, the faculty at the Heller School at Brandeis was world renowned for its pioneering studies in social policy. The doctoral program incorporated this research and knowledge to create a multidisciplinary curriculum different from those of other doctoral programs. Since the Brandeis Pew program targeted and attracted students interested in vulnerable populations, social justice, and social change, a strong curriculum in social policy had already been developed. Now a very strong curriculum in health policy was needed.

The second source of leveraging came from the Health Policy Institute, which had been established in 1978 and became one of the largest academically based health policy research groups in the United States. The institute became an excellent laboratory for fellows who were interested in sharpening their health policy research skills.

Adding Value via Network Effects

PHPP was positioned to become a national program, in which being a Pew fellow would not only mean something to Washington, D.C. policy makers but also to state health policy experts. Over a period of several years, the Pew program developed an outstanding nationwide network of highly trained people. Although PhPP's original mission was to develop policy makers, fellows ended up in a wide variety of health policy positions. As a result, Pew fellows have

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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become extremely mobile. The network is the amalgamation of four or five different program experiences representing dozens of different disciplines and hundreds of personal experiences. As Steve Crane said, "These people understand and know each other, and they can get things done."

According to a 1994 survey of fellows, the greatest value of the program to the fellows was the opportunity to "meet and network with talented scholars and prominent faculty and influential policy makers." For many people, these connections have lasted and have resulted in research collaborations and friendships.

Combining a Standard Curriculum with Customized Elements

In designing a niche program each school must ask: How can we adapt our curriculum and requirements to meet the needs of a mix of individuals with diverse backgrounds? Requiring students to take the required curriculum and participate in dissertation and writing seminars and so on increased program effectiveness and common knowledge bases while creating the sense of a shared experience among fellows. On the other hand, there is a need to customize a niche program to allow fellows to explore new areas of interest.

Although the sites ranged from a lock-step structure at Michigan to near complete academic freedom at BU, each of the programs took steps in which a highly individualized learning program could be offered. The programs learned that too much leniency and flexibility hampered the students' ability to finish the program. As programs moved toward increasing the structure, the challenge became balancing structure with flexibility.

Pew follows have become extremely mobile. The network is the amalgamation of four or five different program experiences representing dozens of different disciplines and hundreds of personal experiences.

At Michigan, for example, competency examinations were used to gauge the student's level of preparation in statistics, economics, politics, and organizational behavior. These requirements achieved three results. First, they forced students to study these subjects before starting the doctoral program. Second, since students were studying for these examinations, they were entering the Michigan program with similar levels of preparation. This increased the job satisfaction of the faculty who in the early years of the program had found it very difficult to teach students with diverse levels of knowledge. Third, the competency exams communicated to the students that they were entering a rigorous program that required them to do some serious work.

The BU program offered the greatest freedom. Although BU did not tell the students what courses they

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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must take, students were advised to take a social science core. To facilitate faster-track fellows, BU allowed them to do course work and the dissertation at the same time. Although the freedom did not work for everyone, several students completed the program in 24 months or less.

The greatest value of the program to the fellows was the opportunity to meet and network with talented scholars and prominent faculty and influential policy makers.

UCSF developed a structured curriculum in which all fellows took the same core seminars. UCSF customized the curriculum on the basis of the type of career trajectory that the fellow desired. Each fellow's needs were assessed through extensive discussions with mentors. Fellows who wanted academic careers were encouraged to publish; fellows who wanted to be become policy makers were encouraged to do research that resulted in reports rather the publications. UCSF learned that allowing people flexibility to search for their own mentors rather than assigning mentors increased the likelihood of survival and success.

Deep Involvement of the Fellows

Program costs decrease if fellows can become more involved in the program. Learning is also enhanced when students are deeply involved in their own education. Throughout the program Pew fellows were asked to give lectures, run seminars, and help with planning and organization. Each year many of the sessions at the annual Pew meeting were organized by fellows and chaired by fellows, and many of the presenters were fellows.

Integrating the Operating Strategy and the Educational Program

For a niche health policy program to be successful, the operating strategy must be integrated with the delivery system. Integration occurred in three ways: learning how to match faculty and fellows, creative uses of technology, and use of integration mechanisms developed by the Institute of Medicine (IOM), as the central program office.

Matching Fellows with Faculty

All of the programs found that matching faculty with students was very challenging. At first the programs tried selling faculty to students or vice versa; for example, at RAND/UCLA the students had to market their expertise to the faculty. Although this approach was not ideal, it helped students to assess their strengths and weaknesses.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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At UCSF some of the fellows had trouble deciding which of the faculty to work with. The program leadership learned that organizing a 2or 3-day faculty presentation was not a good way to expose faculty and their research. Over time UCSF learned how to manage the matching process. Recently, it developed a faculty handbook that contains the type of research that all of the health faculty are involved with.

Application of Computer Technology

The sites ranged from a lock-step structure at Michigan to near complete academic freedom at BU, yet each of the programs took steps in which a highly individualized leaning program could be offered.

The use of technology to electronically link fellows was limited. However, one of the innovators of this approach was the Michigan program. Michigan had to learn how to allow fellows to acquire a doctoral education without interrupting their jobs and careers. To offer fellows a high-quality PhD program in health policy without having to leave their jobs, the program had to find innovative ways to foster and improve communication.

The Michigan program developed on-line computer networks that electronically connected fellows with Michigan health policy faculty. Extensive computer linkages and conferencing between faculty and students had a great impact on the quality and productivity of the off-site program. The use of computer conferencing helped to integrate the Michigan Pew students with their cohorts and the faculty.

Integration Through IOM

Perhaps the most significant way that integration was achieved was through the work of Marion Ein Lewin at IOM. IOM planned annual meetings, developed an annual directory, published a newsletter, and monitored the mission, goals and progress of the various sites. Through the national office, PHPP developed into an integrated program across four sites with a national identity. Moreover, through the efforts of IOM, Washington, D.C. as a laboratory became more accessible to the fellows.

IMPLICATIONS FOR DEVELOPING HEALTH POLICY PROGRAMS AS A NEW EDUCATIONAL NICHE

The previous section analyzed the elements of programmatic success from a strategic standpoint. This section summarizes the implications of the Pew Legacy as a new educational niche programs in health policy. Three questions are addressed: To create a niche educational program, what kind of planning

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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process is needed? During implementation what were the obstacles and how did they influence performance? What lessons were learned from the four Pew programs over the last decade? Answering these questions may provide some useful insights for schools attempting to develop niche educational programs in health policy and other areas.

Many schools of public health, schools of public and social policy, medical schools, business schools, schools of health administration, and schools of social work have begun to offer various programs in health services research. Educational programs cannot pretend to offer an excellent program in a field like health care because it is too large. Therefore, answering these questions can help schools to consider concentrating their resources by developing a niche educational program. These questions are addressed by identifying the activities needed to develop a niche educational program.

Program costs decrease if fellows can become more involved in the program. Throughout the program Pew fellows were asked to give lectures, run seminars, and help with planning and organization.

To help answer these questions, the experience of the creation of PHPP as a developmental process is examined. To help organize the thinking, the Program Planning Model (PPM) developed by Delbecq and Van de Ven (1971) is adopted as an analytical framework. PPM identifies five overlapping phases, each with a distinct set of activities that must be managed. They are as follows:

Phase 1: Planning Prerequisites

To initiate a new program, PPM suggests beginning a planning effort by defining a policy committee and a planning staff.

Phase 2: Problem Exploration

The planning staff begins to collect data on the nature and complexity of problems in the area that the new educational program is attempting to address. The problems are cast from the perspective of the key stakeholders.

Phase 3: Knowledge Exploration

Experts analyze the data on problems and alternatives are generated in a report that is reviewed by the planning committee and circulated among phase 1 and 2 participants.

Phase 4: Program Design

The problems and expert opinions are summarized and workshops and problem-solving meetings are begun with all relevant stakeholders. A demonstration of the program is funded for a trial period.

Phase 5: Program Evaluation, Implementation, and Operation

After a new program is under way, it is periodically evaluated so that corrective action can be taken.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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Although PPM was developed for human service organizations, it can help to guide the design and development of niche graduate educational programs in the future. The remainder of this section explores factors associated with implementation success based on the collective experience of PHPP participants.

Interpreting the Pew Experience

There is very little evidence that there was much systematic planning and goal setting before the start of the Pew program. In 1982 the Pew Charitable Trusts launched the health policy program and made its first awards in 1983. PHPP did not begin with a clear set of well-defined goals. The mission of PHPP was as follows:

To stimulate the development of multidisciplinary health policy educational programs that will equip a cadre of leaders with the required skills to deal effectively with the nation's complex current and future health policy issues.

The original solicitation was unique and impressive because it was based on the recommendations of a small group of advisers to the Pew Charitable Trusts who believed that important policy issues were developing in health care. The foundation, however, made no attempt to define precisely what these health policy issues would be.

During one of the interviews, Stuart Altman commented that the original solicitation was ''unique and impressive" because it was based on the recommendations of a small group of advisers to the Pew Charitable Trusts who believed that important policy issues were developing in health care. The foundation, however, made no attempt to define precisely what these health policy issues would be. Since each of the program sites was allowed to set its own goals, each program truly "owned" these goals and was committed to their achievement.

Through a solicitation process, the foundation targeted 15 institutions and four nonacademic health centers to receive the request for proposal. The foundation selected four university-based centers and 1 nonacademic center as training sites and granted them the autonomy to (1) define these health policy issues and (2) design a training program to address those issues. The foundation allowed the program sites an opportunity to define the major health care problems and to discover a program methodology by experimenting.

According to PPM, success in program development often depends on the amount of professional consultation or technical assistance during planning and implementation phases. During the planning stages, little technical assistance was offered. However, during implementation (under Marion Ein Lewin's leadership) the foundation offered IOM as a "process consultant."

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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As process consultant, IOM did not focus on improving the content of the educational activities; rather it focused on the cohesiveness, communication, and group dynamics of the fellows and training directors. IOM also engaged each of the program directors at each of the program sites in task-oriented team-building activities during retreats and off-site meetings, held in Washington, D.C., at IOM or a mutually convenient location. The program directors would spend a day working intensively; reflecting on PHPP, its problems, and solutions to those problems; and planning joint activities.

As process consultant, the Institute of Medicine did not focus on improving the content of the educational activities; rather it focused on the cohesiveness, communication, and group dynamics of the fellows and training directors.

During implementation, several problems arose: faculty recruitment, faculty complacency and motivation, lack of space, insufficient financial resources, and a general resistance to change. All of the PHPP sites encountered some of these problems. The experience with the Pew program suggests that allowing each program site to define tasks by experimenting with various service concepts and operating strategies worked.

For example, recruitment of faculty and matching students and faculty was one of the most frequently mentioned difficulties. Over time, with the help of the outside evaluations, each program learned how to enlist an excellent faculty. In the beginning the programs aimed for a minimal set of procedures. Structural and procedural ambiguity allowed each program to adapt to student needs. All of the programs discovered that development of new procedures made the programs more effective.

During the early years of implementation, the emphasis of the foundation was on program accomplishments and not on program efficiency (or measures such as total program costs per fellow). At the director's meetings and in the annual reports of the program sites, the focus was on the educational innovations, fellows' accomplishments, number of publications, number of PhDs granted, and so on. Although efficiency is an important criterion for a mature program, the Pew Charitable Trusts displayed great wisdom in its tolerance for ambiguity and its realization that a premature focus on the total cost per fellow in a niche educational program would be a misleading indicator of program success. Had the program directors' meetings or the annual reports focused on efficiency, attention would have been refocused on ways to save money rather than on learning how to run an effective program.

Finally, the experiences of PHPP do not suggest an inevitable move from financial dependence to independence. Neither BU nor the RAND midcareer programs continued

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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after Pew funds were withdrawn. Interestingly, the doctoral program at RAND has continued.

There is not enough information on what happened after Pew support was withdrawn, perhaps because the funding did not last long enough for some of these programs to take root. Although many of the formal mechanisms that helped to coordinate the PHPP structure (orientation meeting in Washington, D.C., annual meetings, directors' meetings, directories of fellows and alumni, and routine newsletters) will end, the surviving sites claim that some type of institutionalization has taken place. Time will tell.

SUMMARIZING THE LESSONS LEARNED: MAXIMS FOR OTHER SCHOOLS

This final section suggests some implications for designing health policy programs in the future. Technically the findings are based on the experiences of the four PHPP sites. Although the findings are preliminary impressions and speculations, the experience can shed fight on how a foundation's strategic choices can affect the success of new educational programs.

Bold and Ambiguous Goals Encourage Active Experimentation

Although efficiency is an important criterion for a mature program, the Pew Charitable Trusts displayed great wisdom in its tolerance for ambiguity and its realization that a premature focus on the total cost per fellow in a niche educational program would be a misleading indicator of program success.

One of the fascinating lessons learned arises around the bold and ambiguous goals set by the Pew Charitable Trusts. First, they wanted to stimulate development of multidisciplinary programs in health policy to train a cadre of leaders. Second, they wanted an accelerated timetable, the tradition of a 6 or 7-year doctoral program was insufficient. Third, they wanted these programs to institutionalize and become self-sufficient, although they would be financially dependent on the Trusts. The goals required everyone—fellows, faculty, and program leaders—to stretch for these goals. Requiring everyone to stretch led to higher levels of performance.

The creation of new multidisciplinary health policy doctoral programs aimed at producing health policy leaders is an ambiguous goal. The Pew program had no historical precedent, so it was guided by ongoing adaptive choices. Ambiguity allowed active experimentation and adjustments when strategic intent and program activities veered away from the core competency of a school. Program site goals were negotiated by the interaction of IOM, the evaluators, the Trusts, and the sites.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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By Encouraging the Programs to Focus on a Single Niche and Educational Service Concept, the Program Flourished

Each of the programs offered a variety of advanced training service concepts in health policy to management fellows, pre-doctoral fellows, and postdoctoral fellows. Although serving a broader set of needs was successful, the Pew Charitable Trusts decided to have each program focus all of its energy on a single concept: nonresidential predoctoral fellows, residential predoctoral fellows, and postdoctoral fellows.

The creation of new multidisciplinary health policy doctoral programs aimed at producing health policy leaders is an ambiguous goal. The Pew program had no historical precedent, so it was guided by ongoing adaptive choices.

The world of health policy is changing because the needs are changing. If PHPP had attempted to satisfy all the diverse needs through one large program, it probably would have failed. Now one can appreciate the wisdom of having multiple program sites with very different program concepts. Although none of the program sites could claim a program that could do it all—produce great academic researchers, teachers, great policy makers, and great practitioners—collectively the Pew program sites were able to serve the needs of the health policy world. The programs learned that focusing on fellows with an operating strategy and a service delivery system specifically designed to meet their needs worked better when a single educational niche was the target.

Importance of Money in Securing the Basics: Space, Stipends, and Faculty Compensation

Without the generosity of the Pew Charitable Trusts, there would be no Pew health policy legacy to speak of. It is difficult to maintain graduate programs in health policy in the absence of strong funding for research and training. New programs are not capable of overcoming the faculty routines, commitments, and lifestyles; institutional memories; and traditional ways of doing educational things.

The conclusion is that money matters. Targeting of excellent students requires the ability to offer them a valuable education (beyond their basic expectation), easy access to the best faculty, and protection from line responsibility. Budgets provide office space, attract high-quality people, concentrate attention resources, encourage innovation, and promote coordination and networking. Building a new program requires large initial investments and reinvestments in academic programs.

Although money matters, focusing prematurely on the dollars spent per student is misleading because it will lead to less success.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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Program Expectations Guide Students

Bowen and Rudenstine (1992) once observed that, ''doctoral programs do not run themselves....much depends on the care with which they are designed and the expectations that are established concerned the character and quality of the work to be done by those admitted" (p. 250).

The world of health policy is changing because the needs are changing. If PHPP had attempted to satisfy all the diverse needs through one large program, it probably would have failed.

In traditional graduate programs, expectations are formed haphazardly out of a mixture of official statements, course requirements and waivers, examinations taken or avoided, peer and faculty pressures, myths and half-truths, and so on. The Pew programs learned that leniency and flexibility are not the same thing. Performance improved when expectations were clarified and when specific expectations were set.

Some of the mechanisms that helped to set expectations in the Pew predoctoral programs were competency examinations and dissertation seminars. The dissertation seminars emphatically stated that that the goal, although not hard and fast, was to help students get started on a dissertation topic in the first semester of the program so that they could defend their dissertation in two or three years. Fellows explained the importance of demystifying the dissertation process. The PHPP approach made a commitment to managing everyone's expectations.

External Program Evaluations Are Real When Financial Dependence Exists

PHPP wanted to stimulate the development of multidisciplinary health policy education programs to produce leaders capable of taking leadership roles in policy development in government and industry. To help understand the degree of success achieved, three formal program evaluations were contracted out. These evaluations helped to focus attention on some of the problems that fellows were having with the way that the programs were being implemented.

These evaluations helped to shape and change the evolution of the programs. They focused managerial attention on (1) how the practices of each of the programs compared, (2) what innovations and outcomes were achieved, (3) how well the programs were serving "Pew fellows as students," and (4) how were the funds being spent. The result was that a balanced scorecard was achieved. There was a focus on four areas: (1) learning and innovation, (2) faculty and fellow satisfaction, (3) business operations, and (4) financial performance. For example, the program that had the weak-

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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est fellows according to the 1985 external evaluation had the strongest fellows by 1989. In general, program weaknesses cited in the first evaluations were corrected by the second evaluation.

Because a commitment structure was established by the foundation through financial dependence, the pressure from these external evaluations led to significant efforts to improve the program. In other words, the programs took these evaluations seriously for fear of being shut-down.3 The evaluations advanced the learning from experience. The reports led to continual moves to improve the curricula and to make them more multidisciplinary, more distinct, more rigorous, and better integrated. The evaluations helped to teach the program sites what seemed to be "good" about the program. Thus, they provided the program sites with a type of feedback, unavailable when programs monitor their own behavior.

Targeting of excellent students requires the ability to offer them a valuable education (beyond their basic expectation), easy access to the best faculty, and protection from line responsibility.

Over time the programs focused their efforts on the needs and perceptions of the fellows and building on the internal core competence of each school. Perhaps the best example of this evolution occurred at the Michigan program...." One of the most striking features today is the degree to which the faculty and the program leadership have learned from earlier experiences, adjusted various aspects of the program, and refined the model to eliminate a variety of dysfunctional characteristics that were noted in the first evaluation" (Richardson, 1990, p 7).

As an aid to developing new programs, schools need systematic ways of analyzing ongoing programs. Without realizing it the external evaluations helped to pressure the programs toward self-improvement, a responsiveness to students, and continuous improvement.

Managing the Tension Between Recruiting Experienced Leaders versus Young, Eager Learners

People with prior experience in complex organizations have developed political and social skills. Often they possess very different kinds of intelligence than the typical doctoral student, who has high verbal and mathematical-logical skills but who lacks extensive real-world experience. Older students with distinguished careers probably have learned a self-awareness and have developed an ability to manage conflict and negotiate with others. PHPP learned that there was a place in the doctoral world for the mature learner. The mix of experienced students with inexperienced students results in a rich, dynamic, and diverse learning environment.

3  

 Funding was discontinued largely for geographic reasons, not performance.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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It Takes Three Years, Not Two

In the absence of a strong structure, the main questions that pre-and postdoctoral students must answer are: "Where do I focus my attention?" and "Where do my research interests lie?" There are infinite ways to address these questions, given the experiences, capabilities, and interests of the individual and given the particular school and educational context. The traditional way to organize doctoral education is to have students learn many research techniques, and to allow them to be distracted by many ideas. In this way, the students' research attention is dominated by coursework in a sequenced curriculum. The result is that the completion rates are poor, and it may take between 5 and 7 years to complete the PhD degree.

There was a place in the doctoral world for the mature learner. The mix of experienced students with inexperienced students results in a rich, dynamic, and diverse learning environment.

The promise of a 2-year program to complete the dissertation attracted many students. Although four Pew fellows finished in 23 or 24 months, the notion of a 2-year accelerated doctoral program was problematic. At BU/Brandeis the average time to completion of the dissertation was 3 to 4 years (Raskin, et al., 1992). The program offered 2 years of protection from job responsibilities; however, after the 2 years the funding ceased and many students, forced to go back to work, were distracted and prevented from achieving "accelerated" completion. An accelerated doctoral program in health policy required 3 years of full-time work with funding.

PHPP uncovered ways in which the predoctoral program could be completed with accelerated timetables. If Pew fellows were to compete their dissertations in less than 2 years, they have to think about a proposal before they take their qualifying examinations in January of their second year. Fellows had to assemble a dissertation committee, and conduct a literature review prior to taking the qualifying exam. This fast track meant that students had to make decisions about how they spent their time. The costs were more serious than the benefits, because a 2-year program meant that Pew fellows had to miss many of the special seminars and colloquia and other learning opportunities.

To Create a National Identity, Joint National Meetings Made Sense

Each Pew fellow had very different professional backgrounds and experiences. Since the programs wanted the participants to create an identity that transcended the boundaries of their program sites, there was a need to meet and talk about

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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shared experiences (Weick, 1995). IOM, under Marion Ein Lewin's leadership, brought people together for retreats providing them with common experiences. These centrally organized events become the glue of the "Pew Culture."

The promise of a 2-year program to complete the dissertation attracted many students; however, the notion of a 2-year accelerated doctoral program was problematic.

For example, during the first year of the program every fellow went to Washington, D.C. The fellows were exposed to the world outside of their particular program. They discovered that there were hot issues and policy wonks, gurus, and experts attached to those issues. Each year an annual meeting was hosted by one of the programs. These meetings brought the fellows together to talk about health policy and participate in "moments of conversation" with leading-edge thinkers and practitioners. These sessions became major learning opportunities.

Without these joint national meetings, there would have been no shared stories, no common experiences, no postmortems on their programs, no sharing of frameworks, and no hope for a network that might outlive program funding. Finally, there would have been no warm sentiment attached to the response, "Oh yeah? I was a Pew health policy fellow, too!"

Analyzing Softer Influences: The Power of a Program to Generate Enthusiasm and Empowerment

To have a more complete understanding of the Pew legacy, one must consider some of the influences that are harder to measure, but understand the enthusiasm of the program leaders and the students at each of the Pew sites. Karl Weick (1995) has argued that "enthusiasm can produce wisdom because action creates experience and meaning." Program enthusiasm partially explains some program success. Enthusiasm was always generated at the program directors' meetings organized by Marion Ein Lewin. The enthusiasm of Marion Lewin and her staff at IOM have clearly given the fellows a "special identity and national recognition."

Another subtle influence on program success (based on interviews with Pew fellows) is the extent to which the interviewed fellows seem to express a sense of empowerment and self-confidence. It was clear that their education gave them an ability to make things happen. All interviewees felt that they had acquired the knowledge and skills to analyze, make, and implement decisions affecting the policy system. The 1994 survey revealed that for many fellows, the Pew program "launched them into better and more influential pro-

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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fessional positions." In the words of one fellow, the program helped people to break "through the glass ceiling for non-PhDs." In the words of another fellow, the program "empowers individuals in their workplace.''

Success Requires Building on Core Competencies

The success of each program was a result of adopting a core competence perspective that required building on the strengths of each school. For the competency approach to work, the program leadership had to perform three basic tasks: (1) identify the existing distinct competencies, (2) improve and develop the competencies, and (3) deploy the competency in novel ways.

During the first year of the program every fellow went to Washington, D.C. The fellows were exposed to the world outside of their particular program. They discovered that there were hot issues and policy wonks, gurus, and experts attached to those issues.

The creation of new educational niches in health policy research requires the development and deployment of at least three competencies: (1) expertise in multidisciplinary policy research, (2) flexible program development, and (3) "faculty focused on students" as a service concept. Turning a new pre-or postdoctoral curriculum into an effective educational program demands an ability to understand the area of study and the educational issues, anticipate student needs, and direct resources to meeting those needs.

The first competency is having a strong knowledge base in health services research and real-world expertise in the health policy sciences. The key indicators of knowledge and experiences are faculty publications, faculty involvement in major policy issues and initiatives, and a strong faculty record in basic and applied funded research.

The second competency for niche creation is "flexible program development." When compared with the lengthy time periods for completion of traditional pre-and postdoctoral programs, niche programs require shorter time periods, higher completion rates, and an ability to accommodate diverse student interests against diverse faculty research interests.

By and large, professional educational programs are built around degree concepts rather than the core competencies of the school. To be successful, the faculty must be focused on the needs of students. Faculty must know what students want, the faculty must accept that student expectations are reasonable, and performance standards must be set. A strong message must go out in the form of a service guarantee everyone (faculty and staff) at the program, without exception, will have a service-oriented attitude (Heskett, 1986).

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
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Institutionalization Takes Time and It's Paradoxical

Funded programs have a life cycle, and death is an inevitable feature. In the case of PHPP, death may not be inevitable. The longer a program survives in a school, the more institutionalized the program becomes—that is, the greater the likelihood that it will survive in the future. Institutionalization means acquiring both stability and status within a school. The degree to which an educational program has achieved institutionalization is defined partly by its age and depends on the degree to which flexibility, autonomy, and coherence have been achieved.

Fellows felt that they had acquired the knowledge and skills to analyze, make, and implement decisions affecting the policy system.

According to Kimberly (1981), "institutionalization is that process whereby new norms, values, and structures become incorporated within the framework of existing patterns of norms, values, and structures" (p. 31). So institutionalization takes time. In the case of the PHPP by the tenth year the programs were just beginning to understand how to make a niche educational strategy in health policy a success. However, innovation and institutionalization often work at cross purposes.

In creating new educational programs, success can be paradoxical (Kimberly, 1981). The problems of getting started and the problems of institutionalization lead to very different attention structures. Being new and different creates short-run opportunities for niche programs because commitment leads to experimentation and tolerance for mistakes (Kimberly, 1981). Eventually, institutionalization leads to formalization and stability, but "diminished innovativeness" (Kimberly, 1981).

The Best Lessons Are Often Unanticipated

As is often the case, program evaluation measures the success or failure based on accomplishing predetermined goals. What's often lost in this type of analysis is an appreciation of the unintended consequences of programs. By observing and analyzing these unanticipated consequences one can also learn some powerful lessons.

At Michigan, for example, the faculty's experience with the off-campus education concept had several positive, although unanticipated consequences for faculty job satisfaction. The faculty found it very rewarding to have these part-time doctoral students coming to the campus to learn and then go back to their full-time jobs to apply that knowledge. Another unexpected consequence was the spill-over effect of the Pew experience to other corners of the school. The

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

financial support from the Pew program made the faculty's policy research and teaching materials available to other health policy students in the school.

HIGHLIGHTING COLLECTIVE ACCOMPLISHMENTS AND PROGRAM IMPACTS

For many reasons, understanding the collective accomplishments of any new educational program are difficult. Program consequences or impacts are often difficult to link (causally) to specific educational activities, because outcomes are ''delayed, confounded, and negotiated" (Weick, 1995). Often people can only understand what they are doing many years after they have done something (Weick, 1995). If one were to fast-forward 10 or even 20 years, what would the Pew legacy be?

One simple, but inadequate, way to assess accomplishment is to count the final outputs produced or services provided. The program produced hundreds of people who have contributed to knowledge creation by publishing hundreds of publications and who will contribute to future health policy visions. Consequences will continue for many years in the future.

Institutionalization means acquiring both stability and status within a school. The degree to which an educational program has achieved institutionalization is defined partly by its age and depends on the degree to which flexibility, autonomy, and coherence have been achieved. However, innovation and institutionalization often work at cross purposes.

Another measure of accomplishment is to track job changes over time. Table 6 lists various health policy fields and Pew fellows' migration paths before and after attending the program. Although the entire program has helped to place many people into a variety of health policy positions, each of the program sites has had different impacts.

The BU/Brandeis and Michigan programs saw significant shifts into academic positions (from 21 percent to 37 percent and from 8 percent to 28 percent, respectively). BU/Brandeis, University of Michigan, and RAND/UCLA had greater shifts into research jobs (from 0 percent to 10 percent, 4 percent to 8 percent, and 9 percent to 20 percent). UCSF had some shifts to consulting (15 percent to 8 percent) and government (12 percent to 17 percent). UCSF and Michigan had small shifts into health care management (from 13 percent to 17 percent and 22 percent to 26 percent, respectively).

When one considers the range of positions occupied by Pew fellows today, one finds that there are few problems in the domain of health policy issues that lie out of some Pew fellows' reach. In one sense the program has fostered an invisible health policy college with a network of potential allies. It is presumed that Pew fellows will continue to improve the formulation and implementation of health policy. Whether this

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

Table 6. Migration Paths of Pew fellows by Program Site Before and After Attending the Program

 

BU/Brandeis

UCSF

Michigan

RAND/UCLA

Total (all programs)

Field

Before

After

Before

After

Before

After

Before

After

Before

After

Academia

14/67 (21%)

25/67 (37%)

34/83 (14%)

38/83 (8%)

4/50 (8%)

14/50 (28%)

23/69 (33%)

23/69 (33%)

74/269 (28%)

98/269 (37%)

Consulting

4/67 (6%)

9/67 (13%)

1/83 (1%)

7/83 (8%)

4/50 (8%)

3/50 (6%)

3/69 (4%)

3/69 (4%)

12/269 (5%)

22/269 (8%)

Research

0/67 (0%)

7/67 (10%)

2/83 (2%)

3/83 (4%)

2/50 (4%)

4/50 (8%)

6/69 (9%)

14/69 (20%)

10/269 (4%)

28/269 (10%)

Government

19/67 (28%)

5/67 (7%)

10/83 (12%)

14/83 (17%)

16/50 (32%)

8/50 (16%)

10/69 (14%)

8/69 (12%)

55/269 (20%)

35/269 (14%)

Health Care Management

17/67 (25%)

7/67 (10%)

11/83 (13%)

14/83 (17%)

11/50 (22%)

13/50 (26%)

14/69 (20%)

11/69 (16%)

53/269 (16%)

45/269 (17%)

Professional Associations

1/67 (2%)

3/67 (4%)

0/83 (0%)

1/83 (1%)

4/50 (8%)

3/50 ((6%)

1/69 (1%)

1/69 (1%)

6/269 (2%)

8/269 (3%)

Other

7/67 (10%)

1/67 (2%)

15/83 (18%)

3/83 (4%)

6/50 (12%)

3/50 (6%)

4/69 (6%)

4/69 (6%)

32/269 (12%)

10/269 (4%)

Data Missing

5/67 (7%)

10/67 (15%)

10/83 (12%)

3/83 (4%)

3/50 (4%)

2/50 (4%)

8/69 (12%)

5/69 (7%)

26/269 (9%)

18/269 (7%)

NOTES: The data for classes entering 1983 to 1993 are included. All information retrieved from Pew directories corresponding with year of entry The "Other" category, described in greater detail elsewhere, includes fields such as: clinical medicine, communications, and business.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

potential network is used to help in major health reform or restructuring efforts in the future remains to be seen.

It was found that the program affected the program sites, the fellows, the faculty, IOM, the Pew Charitable Trusts, and the health policy world. Each of these will be discussed in turn.

Program Sites

If one were to fast-forward 10 or even 20 years, what would the Pew legacy be?

According to leadership at each of the program sites, the schools benefited in a number of ways. Each program site learned how to organize a curriculum and a faculty that satisfied program faculty, students and external evaluators. Each program site also developed a methodology for the multidisciplinary training of predoctoral and postdoctoral students, and they were able to leverage these programs into larger educational domains.

Today UCSF has a health policy specialty that would not have existed without Pew support; it now has seminars and courses that would not have existed otherwise. For example, at UCSF a writing seminar and a health policy seminar that met every week built on the experience of the Pew program to develop an Agency for Health Policy Research training program, and interdisciplinary scholarly work came as a result of Pew. The Institute for Health and Aging would not have existed without the Pew program. The Pew program led to the development of a successful joint University of California at Berkeley/UCSF proposal to the Robert Wood Johnson Foundation for a program in health policy.

Brandeis was also able to extend the Pew experience into a successful new predoctoral program in health services research funded by Agency for Health Policy Research. RAND/UCLA found ways to sustain a commitment to the Pew approach to training and educating doctoral students. Finally, Michigan learned that the OJ/OC concept could work in doctoral education.

Fellows

Each of the programs contributed to the fellows' professional lives in several ways. Many fellows spoke favorably about the education they received. The education helped many fellows to think about health policy in a rigorous way, expanding their knowledge of policy and their research skills. Fellows also claimed that they learned about the role of science and knowledge in political institutions.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

Some fellows felt that they had obtained the credentials to be more legitimate and convincing advocates. The program also introduced fellows to multidisciplinary education. As a result, fellows claimed to have become better "policy colleagues" by developing a greater awareness, appreciation of, and respect for what their colleagues in other disciplines do.

Faculty

Pew fellows will continue to improve the formulation and implementation of health policy. Whether this potential network is used to help in major health reform or restructuring efforts in the future remains to be seen.

The program also had important impacts on the faculty in every program. UCSF faculty spoke of the Pew experience as "broadening, offering faculty a chance to enrich their work-loads and their professional careers." This enrichment occurred in several ways. Faculty claimed that the Pew courses were fun to teach, often exposing the faculty to challenging and stimulating sessions. Faculty, especially in the postdoctoral programs, wrote many papers with Pew fellows. When faculty worked with Pew fellows, they found that they were affected by them. For example, Pew faculty also learned to be better "policy colleagues" by working with fellows from disciplines other than economics—law, medicine, management, political science, and sociology.

IOM

IOM also benefited from the Pew fellows, who continue to add a fresh voice to the policy work of the program. IOM has hired Pew fellows and commissioned papers and reports from Pew fellows. The rigorous training received by Pew fellows will continue to serve IOM in the years to come as fellows are called upon to help it deal with contemporary issues.

Pew Charitable Trusts

For all the reasons cited above, it appears that the Pew Charitable Trusts have also benefited from the program. This program was one of the Trusts' first efforts that was national in scope. The program has been considered a tremendous success by the external evaluators and the health policy world. During the last decade, the effort took on all the characteristics of a "signature program" for the Trusts.

Health Policy World

One can speculate endlessly on the presumed impacts on the policy world. But the most significant impact of the

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

program has been the placement of highly educated people in strategic health policy positions in virtually every segment: academia, research and consulting, government and public health, professional associations, and health care delivery. Each individual has a unique set of special skills, yet each fellow is trained to understand the multidisciplinary nature of health policy. Each one is trained to translate research findings into policy-relevant and managerially relevant language. Each one is given an awareness of how politics, markets, and organizations works in health policy. Each one has an appreciation of the significance of knowledge in making better policy. Each one is committed to lifelong learning.

Between 1991 and 1996 Pew fellows and alumni published about 650 scholarly papers and technical reports covering a wide variety of health policy subjects.

Years

Estimated Number of Publications4

1991–1992

106

1992–1993

127

1993–1994

159

1994–1995

165

1995–1996

92

Total

649

As one considers the contributions to knowledge made by these publications, one is reminded of Peter Drucker's insight into the central role of the individual: "Knowledge does not reside in a book, a databank, a software program; they contain only information. Knowledge is always embodied in a person; carried out by a person; created, augmented, and improved by a person; applied by a person; taught and passed on by a person; used or misused by a person" (Drucker, 1993, p. 210). According to Drucker, knowledge production is enriching, but the advancement of knowledge requires human action, and that requires defining a role for people. Envisioning a role for Pew fellows in the future is the subject of the final section.

ENVISIONING A FUTURE POLICY ROLE FOR PEW FELLOWS

In the coming years, health policy will continue to be a high-drama, high-stakes, high-social-purpose field. With a growing underclass of vulnerable subpopulations, and with managed care and competition causing strategic re-orientations,

4  

 These estimates are based on self-reported figures given to the Program Office at IOM. It is likely that the actual number of publications is 20 to 40 percent higher.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

alliances, and changes in finance and payment, the world of health policy becomes ever more complicated. Health policy makers will be central characters in this drama.

Today, health services research and health care management have emerged as new disciplines capable of making important contributions to health policy (Ginzberg, 1991). A recent study found that the demand for highly qualified health policy researchers would continue to exceed the supply (Field, et al., 1995). If the health care system needs more health policy scholars, doctoral education and postdoctoral programs focused health policy will remain important social investments. More well-educated people will be needed.

The most significant impact of the program has been the placement of highly educated people in strategic health policy positions in virtually every segment: academia, research and consulting, government and public health, professional associations, and health care delivery.

It is hoped that the Pew fellows will become the self-appointed "trustees" of this new health policy world.5 Amidst the growing complexity, neither government nor the delivery system can afford to shoot from the hip. The health care delivery system of the future will be assigned responsibility for vulnerable populations. These organizations must develop an unprecedented capacity to learn—which includes understanding the issues and framing them as policy questions, discovering new theories, developing and deploying them, and evaluating the outcomes on the populations. To paraphrase a quote made by a hospital chief executive officer in the midst of this sea change:

"Today the familiar paths no longer seem to work. This time we will have to think our way out of this situation; because we can no longer simply buy our way out."

—Personal communication with a Boston-area hospital CEO

[emphasis added is the authors']

That quote suggests that innovations in health policy will require abandoning old ways. Thought needs to be given to the knowledge base for policy makers, the need for better-educated policy makers, and the need to get off the treadmill to begin generating new ideas.

As one reflects on these lessons, one can see the need for health reform to be greater than ever. However, the future world of health policy does not need a brilliant leader with a vision. Health reform can be characterized as a massive construction project in need of academically oriented, meta-policy architects:6

  1. Policy architects who are willing to advocate the social values that underlie desirable consumer and producer behaviors (responsibility, social justice, caring, and so on).

  2. Academically-oriented architects who are continually sharing their deep understanding of the evolving needs

5  

 Borrowed from former Ambassador to Great Britain, Kingman Brewster, who asked, "Who are the Trustees of the future."

6  

 The role of meta-architects was first described by Charles Handy (1990).

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

of patient populations and the nature and capacity of the delivery system.

  1. Practice-oriented policy architects who are producing knowledge and vision for the health policy world.

For several reasons, there is an opportunity for a collective rather than an individual role for Pew fellows. First, the difficulty of concentrating attention on more than a few policy issues at a time is a severe limitation for the health policy world. If, for example, one were to rely on the media to frame the health issues, the end result would be a faddish and transient agenda rather than an intellectual agenda (Simon, 1983). Without a group whose mission is to systematically identify and solve policy problems, attention drifts away from issue A to issue B to issue C.

Innovations in health policy will require abandoning old ways. Thought needs to be given to the knowledge base for policy makers, the need for better-educated policy makers, and the need to get off the treadmill to begin generating new ideas.

Second, since most complex health policy issues are dynamically complex, single experts can have damaging effects on health policy. Rather than contribute to the pool of knowledge, experts and gurus often become symbols representing positions taken (pro and con) for any given solution. Knowledge can take generations to assimilate, but experts become "creatures of media machines" (Rieff, 1972). We prefer groups of people working together in teams because groups (when compared with individuals) have more information to share, have greater breadth and depth of experiences, and have the capacity to use multiple lenses. Therefore, by enlarging the pool of ideas, groups have the potential to produce higher quality and more effective policy decisions.

Third, Herbert Simon continually reminds us that each individual only sees the part of the world in which he or she lives and tends to aggrandize the importance of that part (Simon, 1983). Since Pew fellows are located throughout the policy world, no individual can see the whole world. Each fellow sees that part of the world that he or she knows. There is a need to share information.

Fourth, from a health policy standpoint, the delivery of health care depends on expectations about the future and the market's reactions to those expectations, and these are difficult to study. So, to understand the alternatives and their consequences, policy research and development and demonstrations in health care need to continue. For all these reasons there is a need for sustained attention from Pew fellows as a collective group.

Today there is a living, breathing network of more than 300 Pew fellows with a significant opportunity to influence health policy development. To be effective in health policy,

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

there will be a continued need for Pew fellows to bridge three cultures: (1) academia and intellectual research, (2) polity, and (3) health care delivery systems. The intellectual community must continue to focus on language and ideas, the polity must focus on the realpolitik allocation of values, and the delivery system must focus on people and services. The emotional and intellectual energies of those fellows will continue to make a tremendous difference if actions such as the following are taken:7

Today there is a living, breathing network of more than 300 Pew fellows with a significant opportunity to influence health policy development.

  1. Translate and frame academic knowledge into policy-relevant and managerially relevant language.

  2. Develop mechanisms to enlist new health policy fellows by: (a) establishing a new professional association or (b) establishing a virtual or invisible college, perhaps at the original program sites.

  3. Launch a "virtual Pew program" in which Pew fellows will continue to share their collective knowledge, ideas, and other resources through distance learning technology, electronic networking, formally organized conferences and colloquia, and possibly, new policy publication outlets.

  4. Maintain current information about Pew fellows and their locations in academia, federal and state government agencies, corporate organizations and the delivery system via a home page on the World Wide Web, newsletters, and phone directories.

  5. Continue to hold annual reunions aimed at developing commitments to an intellectual agenda.

  6. Continue to read, synthesize, contribute to, and disseminate the literature.

  7. Continue to validate and refresh the policy-making inputs—the data, information, knowledge, and theories.

  8. Track fellows global presence in health policy by developing a capacity to disseminate local knowledge through the Pew network and infrastructure.

For these actions to happen, there will be a need for a leadership group to emerge, with leaders willing to find common values and shared expectations and instill a deep respect for those areas where differences exist. These leaders who will not merely project the current system incrementally into the future, but will play with new ideas, discover new zones of study, and look upon change with what Karl Weick calls "disciplined imaginations."

This report has tried to capture some of the feelings and some of the spirit of the Pew Health Policy Program in its attempt to stimulate multidisciplinary education in health policy. By writing about this experience, it is hoped

7  

 Some of these ideas come from Hamel and Prahalad (1994) and Handy (1990).

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×

that something has been done to encourage people to think about the future. Health policy remains a vast subject, with an ability to affect human lives in extraordinary ways. The only possible conclusion that can be reached is that health policy has just begun to be studied. We believe that Pew fellows will continue to play a critical role in leading the effort.

Suggested Citation:"Part 4: Summarizing the Legacy: Some Conclusions and Thoughts for the Future." Institute of Medicine. 1997. The Lessons and The Legacy of the Pew Health Policy Program. Washington, DC: The National Academies Press. doi: 10.17226/5821.
×
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