Academic medicine is a classic loosely-coupled system. Some leaders describe it as organized anarchy. The traditional independence of physicians and scientists from hospitals and medical schools, often reinforced by differences in their economic interests, make change efforts particularly challenging. This independence is reinforced by the proliferation of semi-autonomous, self-funded programs, centers and institutes. Many institutions also experience a gulf between physicians or scientists and administrators and between clinical and basic science faculty that makes it difficult to bring complete information to the table to address complex system-wide problems.

At the same time, changes in the content and organization of biomedical knowledge, the rapid emergence of new technologies and specialties to go along with them, resource constraints and a tighter regulatory environment demand thoughtful and sustained change efforts. CFAR works with hospital and medical school leadership, as well as specialty societies to address complex institutional challenges. We apply a number of tools and approaches we've developed over time and in diverse institutional settings to engage key leaders and address complex decisions. Under different circumstances, our efforts might include:

• Creating an integrated story about the future or direction of the enterprises that includes the key scientific, educational and clinical decisions, and also the financial and resource base on which those decisions are built. These integrated stories help to ensure that the efforts of a broad range of groups and individuals are consistent with the overall strategic direction of the institution.
• Undertaking a change campaign around a strategic theme. Engaging allies around the institution to push forward a change agenda, recognizing the differences in their particular interests and concerns.
• Negotiating agreements around challenging issues, for example, the leadership structure of a practice plan, or new cross-department center, by welcoming and working with differences in perspective, skill and experience.