Culture transformation by stealth: Leveraging incremental change to revamp the curriculum.

Introduction: Reshaping an existing education program from traditional structures and processes into competency-based medical education (CBME) is formidable. Emory University School of Medicine applied organizational change theory to introduce CBME into an established MD program by employing 'sustainable innovation', which introduces change incrementally.

Methods: Implementation of CBME began with the identification of core institutional values. Using the sustainable innovation approach, the first change was adoption of new program outcomes and student performance expectations. There were few changes that occurred to the structure of required courses and clerkships. This intentional approach allowed stakeholders to familiarize themselves with CBME prior to full implementation.

Results: Existing assessment processes remained intact while the faculty was trained for innovative assessment uses. For example, the assessment process was augmented by tagging all exam items using a controlled taxonomy and students' performance was linked longitudinally. Using sustainable innovation allowed time for data collection and evaluation throughout the implementation of CBME.

Discussion: Representing student achievement according to competencies, rather than as letter grades, is perceived as revolutionary by many stakeholders. Employing sustainable, incremental innovation facilitated stakeholder buy-in to the underlying principles of CBME. Fostering a new organizational culture will be the 'rate-limiting factor' for full implementation of CBME.