The Landscape of the System: Where Change Happens

The Landscape of the System: Where Change Happens

Based on the problem areas that were previously identified by students, we mapped those on the functional areas of ISMMS to identify six spheres:


1. Admissions

2. Clinical

3. Curricular Affairs

4. Students

5. Student Affairs

6. Student Resources

All of the RBI change targets will focus on these six spheres. Interested in the scope, terrain and interconnectedness of these spheres?

Admissions Sphere

Our terrain is multi-faceted, rapidly evolving with each application cycle heavily influenced by an aspirational mission deeply ingrained in our sphere. With each cycle we are repaving our terrain with new players, new directions and exploration. Within the larger Admissions sphere, we have identified five working-groups that we consider essential to our continued success:

  1. Leadership and Staff
  2. Selection and Decision-making Committees
  3. CMCA and Pipeline Partnerships
  4. Students: Screeners, Interviewers, Reps, Hosts, and Tour Guides
  5. Marketing and Event Planning

In addition, we foster indispensable relationships and overlap with other multiple spheres as students’ progress from applicant to matriculated student encompassing Enrollment, Financial Aid Services, Student Affairs, Housing, and the International Office. A uniquely challenging component of defining our terrain is development and projection of a polished outward veneer that involves accurately branding and marketing the institution to incoming applicants. We are dynamically poised to project the attributes of a modern top-ranked institution that embodies the rigor of academics and commitment to service that Icahn School of Medicine is known for, while ensuring that matriculated students are provided the holistic and nurturing learning environment, as advertised.

Our team cultivates this terrain to produce clear deliverables that enrich the learning environment in other spheres: we are the first point of entry and subsequent gateway for defining and ensuring academic excellence. Indeed, the onus of actively recruiting and selecting a diverse, academically competitive, happy and healthy student body is primarily ours.

Since our constituency is comprised of aspiring, often young applicants accustomed to a foreign sociocultural terrain, we yearn to truly understand their modern lived experiences and identities. We are constantly pushing to overcome the generation gap between applicants and our working-groups, namely the committee. We accomplish this by incorporating innovative faculty and student development into the process, translating the nuanced distance-traveled vernacular of our incoming contingent.

Specifically addressing race and bias within our sphere has been a priority in admissions. Our core team and committee understand the need for diversity in all realms and holistically evaluate each applicant, deeply appreciate challenges faced due to poverty, illness, disability and health care access—all of which intricately involve perceptions of race and bias. Injustices experienced by applicants such as micro-aggressions or structural biases, however, are more challenging for many of our stakeholders to fully appreciate and apply in the admissions process. This deeper understanding is imperative for our sphere’s success. We are becoming more evolved with each cycle, learning from prior mistakes and constantly championing success to attract the very best students to this institution.

Clinical Sphere

Addressing the racism in interactions between people in the clinical environment will be an integral part of eradicating racism at Mount Sinai. However, these interpersonal interactions are often informed by (and, indeed, inseparable from) the overarching systems that enable racism. All too often, our tendency is to attempt to address racism by solely focusing on interpersonal interactions without addressing the underlying systems that inform those interactions. To avoid this pitfall in our current work, we must specifically name and focus our attention on addressing these underlying systems.

For the clinical environment, the underlying systems that inform our interpersonal interactions are:

  1. Hierarchy
  2. Disparity
  3. Racism
Curricular Affairs Sphere

Our terrain seems to be ever-changing and evolving.  It is one deeply rooted in racism and bias, but also one now dedicated to self-evaluation and transformation.  We also work in a terrain that is dependent on broader systems and structures (i.e., health policy, health systems, accreditation, licensure, and assessment), but one that is able to influence these systems in unique and powerful ways.

There is a vulnerability to our format of teaching and learning: we obtain data following experiences and we use these data and findings to improve how and what we do for subsequent generations of students. So while we can and do make changes “in time,” we are most often responding retroactively rather than proactively and that lends itself to a perspective that our terrain/sphere is reactive rather than proactive.

Knowledge is constantly evolving and, as a result, teaching around topics in terms of language, social representation/acknowledgement has to evolve as well. Unfortunately, there is a lag between new knowledge integration into the teaching space.

Student Sphere

We as a sphere represent the voices of the student body at Mount Sinai, with an emphasis to advocate for students of color (SOC) at this institution. We wish to uplift the voices of students who are underrepresented in medicine, who are subject to racist and biased practices on a daily basis at our institution.

Students of color at Mount Sinai, particularly those underrepresented in medicine, namely, Black and Latinx students, are those who are most impacted by administrative policy and decision-making or lack thereof, and are also those with the least power, autonomy, or agency. Therefore, it is critical that their voice is not only heard, but integrated into all decisions made within the medical school. To begin this work, it is critical that RBI acknowledges the efforts and sacrifices of students, particularly SOC, who began this work often in many instances against the resistance of other actors in power. Thus, the RBI should invest in providing voice and acknowledgement to originality of this work and should continue to refer back to narratives already provided by students for guidance and framing. For those reasons, student ownership must be a central tenet of the RBI and is key to its legitimacy as a transparent, accessible initiative. We are the sphere that sits at the crux of all other spheres and we are the primary stakeholders in any decisions or changes made in this process. Therefore, we need to emphasize the experiences of students and how they must align with each sphere’s agenda/mission.

The culture and climate of the student sphere is inherently different for Black and Latinx students and students of color. When admissions practices result in the failure to recruit those underrepresented in medicine, students of color are further marginalized, isolated and under-supported within their respective cohorts. When attitudes within the clinical sphere result in racist and biased evaluations, students of color are limited in their opportunities to equitably move forward in their academic careers. When the curricular content provided to students further propagates racist and biased practices, these values are ingrained within the training of students—our future physicians.

When students of color are not supported financially with adequate resources for success, we fail to provide students of color the opportunity to perform to the best of their abilities academically. Despite these barriers, which are not limited to what is named above, students of color, and specifically Black and Latinx students, have shown perseverance, diligence, and strength to succeed at this institution.  We hope that as we enter Phase 3 of the Racism and Bias Initiative, we will be able to identify specific change targets that will continue to address the gaps within all of the spheres by utilizing the voices of students that are primarily subject to the inequitable structures at Mount Sinai.

Student Affairs Sphere

Despite the feeling that we are unsure of what change will look like, we are hopeful that we will be able to serve URiM students better. We are grateful to be engaging in this process and trust that the process will lead us to change targets that will improve the medical experience for URiM students. The process is both ambiguous and amorphous while being directive and purposeful.  We are sure that more student input is necessary.

Landscape of our Sphere

We work on the terrain of nurturing and guiding students to help them navigate the medical school experience. Our goal is to assist students in clarifying their focus in mapping a career path that meets their individual needs, and to achieve the skills and tools necessary to meet their goals.  It is a give and take relationship; we get feedback from the students on their experiences and that feedback helps us to improve their experience.

Some of the terrain is shaped by external forces, for example: requirements set by outside organizations (such as NBME); residency application requirements; the make-up of faculty in academic medical centers, hospital requirements, student loans, and more. These external forces can contribute to making Student Affairs into the enforcers of rules and policies and ultimately the “bad cop.”

We work in terrain that has been shaped/established for decades by a predominantly White male group and therefore, policies and practices often reflect a White male dominated perspective. This White male perspective emphasizes perfectionism, order, morals, and schedules while deemphasizing emotions and flexibility.

Student Affairs is currently a very diverse group of physicians, educators, and advisors. Through this initiative, we will be able to examine our perspectives and ourselves. In this self-reflection, we will be able to improve our skills in advising medical students.

We are becoming a more diverse group not just culturally and ethnically, but as well in our skill sets (i.e., learning specialist, wellness programming).

We commit to being more willing to accept feedback and criticism from students and other faculty, and to act on that feedback.

For some students, we seem like overbearing nagging parents and only come to us when there is a certain threshold that is reached. Some students, especially students of color, feel like Student Affairs is defined by task completion, disciplinary action, and where students go when they are in trouble. Student Affairs “knows too much”, and are seen as perpetrators of the status quo.

We commit to lowering that threshold with students by committing to longitudinal relationships that celebrate successes in addition to addressing obstacles.

Student Resources Sphere

In the Student Resources Sphere organizational knowledge is paramount. The terrain is complex and intersectional. We work regularly with students, faculty, and staff in a dynamic and ever-changing environment.

Our work is centered on creating equitable opportunity and support for all students to have the resources they need to succeed and the capacity to achieve their best during their medical training. Because of its complexity, the players in the student resources sphere must be without bias and intentionally focused on equity, practical, rational, and able to provide solutions under pressure.  Our terrain is stressed by limitations in physical space and lack of needed human resources. To counter-balance the stressed terrain we need to nurture our own growth with quality training and all that we imagine that to be.  Training provides a clarity of our goals, and clarity is one of the greatest energizes.  Training also provides the space and time we need to become pro-active, to allow ourselves to anticipate our needs, and plan for future change.

The Student Resources Sphere is unified in the goal of being supportive and engaged with students to ensure they have the opportunity for growth and development, financial stability, health care, housing, and a safe and sustainable learning environment. We want to become the team that students know will provide resources, tools, and support without bias, racism or judgement. We want to offer options and be solution-driven and have a strong presence in creating a rich environment that will provide a foundation and structure to our students, as they navigate through their education at ISMMS.

We provide tools, systems and support to students, with a goal of providing excellent customer service.  We should routinely evaluate processes and systems with an eye towards streamlining and improving efficiency, as well as identifying and mitigating barriers to success and support. Often, the outcome of this evaluation leads to measures which seek to avoid risk and marginally improve content. We have to become a group that thinks bigger and more proactively, with an eye on transforming people and processes.  A common theme for our future vision should be to find creative ways to allow ourselves to be more proactive, and less reactive. We need to establish and continually reaffirm trust with students.  We are passionate, committed and optimistic.  We are becoming informed leaders on the topic, and if managed strategically, will alter the face of our organization.

There are many areas in our sphere that have been impacted by conscious and unconscious bias and structural racism, that have resulted in poor student experiences. Students of color in particular, have not felt secure or welcomed in many areas on our campus. The systems we have in place for security, housing, financial aid and others, despite their good intentions and efforts, have bias and many are rooted in systems that do not allow all students to thrive and to be successful. Some of our processes are not flexible which does not allow for a changing landscape of self and racial identity. Our understanding of the type of support needed for students from disadvantaged backgrounds is lacking. Our responses, if better informed would be sufficiently robust to ensure their success in our program.  Our perception of possibility is sometimes limited because we operate at max capacity and have little choice but to be content with the status quo. It can feel as though there is not enough time for creative problem-solving.  All of these areas have gaps that will be addressed as we move towards our future vision.

Rethinking with Systems Thinking

Rethinking with Systems Thinking

We can all agree that telling people to change the way they act or talking about how we envision change isn’t sufficient. If we want to change behavior, we need to change the system that drives that behavior. A systems thinking perspective forces us to look at the whole, not the individual parts, and highlights what lies beneath some of the seemingly intractable inertia as we try to achieve meaningful change.

Scroll on and learn more about systems thinking and how RBI is applying this perspective to ISSMS’s change management strategy.

Systems Thinking enables us to:

  • Understand how ISMMS and other complex systems really function.
  • Change our own thinking to match the way ISMMS operates.
  • Change our behavior so that we are working with these complex forces instead of against them.
  • Develop greater appreciation for the impact of our change targets on others in the system.
  • Be aware of the need to balance short-term and long-term objectives and strategies.
  • Anticipate unintended consequences of well-intentioned strategies and change targets.

Systems thinking is driven by these principles:

  • Considering the “big picture”
  • Seeing the dynamicand complex whole
  • Knowing the interdependent nature of the system
  • Recognizing the interrelatedness of parts
  • Thinking about what happens over time
  • Balancing short-term and long-term perspectives
  • Noting the measurable and non-measurable factors
  • Accepting complexity and uncertainty
  • Knowing that we are part of the system (and the problem)
  • Knowing that today’s problems are from yesterday’s solutions
  • Examining interactions that are the most relevant to the issue at hand, regardless of organizational structure or hierarchy

Admittedly, systems thinking is difficult because often people:

  • Default to a reductionist point of view
  • Focus on immediate, short-term solutions
  • Are narrow or short-sighted in perspective
  • Engage in linear thinking (X causes Y) that doesn’t illuminate the complexity of the system

If you are a Mount Sinai employee, there is a training on Systems Thinking offered by Talent Development & Learning.

You cannot identify where and what should change without first understanding the system.

RBI’s Change Management Phase 3

An integral aspect of our strategy is to more broadly enable ISMMS to engage in systems thinking to identify what needs to change in order for us to provide health care and education that is free of racism and bias.  In June, the Guiding Coalition Change Leaders hosted a series of 12 interactive sessions with faculty, staff, students, and other stakeholders. During these sessions we used systems thinking tools such as the iceberg model to help us ask the right questions so that we can understand the best places to “leverage change” in the system. For a recap of the sessions click here.

Small changes can produce big results, but the areas of highest leverage are often the least obvious. The most grand and splashy solutions—like changing policy, vision, or branding—seldom work for transforming culture. Small, ordinary but consistent and repetitive changes can make a huge difference. Check out where each sphere is at in identifying change targets.

Want to see what patterns, underlying structures, mental models and cultural and institutional values we uncovered during our sphere sessions? Read on.


Change Management Meets the Racism and Bias Initiative | An Introduction to the Methodology from Dr. Leona Hess

Change Management Meets the Racism and Bias Initiative | An Introduction to the Methodology from Dr. Leona Hess

A New York-native, Dr. Hess is a systems thinker and transformational change strategist. Joining Med Ed in October of last year, her primary role is to develop and apply a Change Management methodology to the Racism and Bias Initiative (RBI). By doing so she will build our collective capacity to effectively lead and implement transformational change towards our future state of providing health care and medical education that is free of racism and bias. Over the past few months she has worked with key stakeholders to begin to build out a more formal Change Management strategy that is bold and collaborative.

We caught up with Dr. Hess to find out about what Change Management is and how it will be applied to the RBI.  (more…)