April 19, 2010
Getting Better?
By Iain Crawford, University of Delaware
A few years back, Bob Connor wrote in this blog about a New Yorker essay that had had a powerful impact upon him -- Atul Gawande’s “Bell Curve.” The essay, which Gawande later included in his collection Better: A Surgeon’s Notes on Performance, describes the range of outcomes for centers that treat cystic fibrosis, outcomes measured in life expectancy for their patients. These outcomes fall into a bell-shaped curve, with a few centers at the best and worst ends of the spectrum and the majority falling into the large middle bulge. In 1997, the practical meaning of the curve was that a patient being treated in an average center could expect to live just around thirty years; those at the top center had a life expectancy of forty-six, a gain of over 50%. Gawande’s diagnosis suggests that two essential factors determine whether an institution can move its performance out of the middle range and to the right side of the bell curve: the presence of a transformational leader, and an overarching institutional willingness to commit to doing whatever is necessary to achieve change. Underlying the two factors is a further prerequisite: a readiness to be utterly transparent about one’s outcomes and efforts to improve them.
What intrigued Bob Connor about Gawande’s essay was the questions it posed for higher education: is there a similar bell curve for our institutions? if so, how would it match up with existing rankings, such as those in US News and World Report? and, is it possible for an institution to significantly change its performance? Like Bob, I found this an extraordinary essay when I first encountered it – and indeed I’d heartily recommend Gawande’s book to anyone interested in how organizations can reinvent themselves through a process of improving the basics of practice. Rereading the essay recently, however, I found myself asking some other questions and wondered whether higher education is getting much closer to tackling the issues Gawande describes and whether we are much closer to making the kinds of change for which he calls? Specifically, how fully and how deeply has higher education embraced assessment of its work in the way that cystic fibrosis centers have used it to improve their outcomes?
For me, one of the most educative experiences of the past decade has been the opportunity to serve on teams visiting campuses as part of the accreditation process – it’s a marvelous opportunity to plunge deep into another institution, explore its processes and culture, and learn how, in ways both like and unlike one’s home institution, it goes about trying to accomplish goals of liberal learning. On every visit, assessment has emerged as a significant issue and prompted a range of questions for the team: why has this institution not really begun to assess student learning? Why did that campus respond so well to the report of the last visiting team, do good initial work with developing assessment measures, and then lose impetus a few years later? How can any institution engage in assessment in a way that helps it become something that faculty and staff find meaningful and even essential to their own fundamental work with students? And last but not least, what can be done to help college presidents move from seeing assessment as a hurdle to be got over rather than an opportunity to help them shape their institution? Time and again, one or more of these questions takes shape as the team learns during its visit, through the accumulation of individual conversations, just where the campus culture truly stands on developing its understanding of student outcomes. Moreover, just as Gawande found with hospitals, perceived institutional quality provides no guarantee of success: last year, by luck of the draw, I had the opportunity to be on three teams visiting institutions ranked among in the top 15 national liberal arts colleges by US News. In each case, the campus was facing significant challenges around assessment and, above all, still clearly needed to be persuaded that assessment could be intrinsically valuable rather than merely an externally imposed requirement.
A significant part of the challenge, in both medicine and higher education, lies in fundamental issues of organizational culture. When Gawande visited the top-ranked center for treating cystic fibrosis, Fairview-University Children’s Hospital in Minneapolis, he found those factors he saw as essential to improving outcomes: charismatic leadership, overarching institutional commitment, and transparency. However, he also saw “a degree of uniformity that clinicians usually find intolerable” and, what one doctor described as the director’s absence of “collegial respect for different care plans.” To improve outcomes in higher education our most daunting challenge may well be neither the accrediting agencies nor the US Department of Education, but, rather, something that is also the source of our greatest strength: the intellectual diversity and mandate to explore one’s field that we tend to encode into the concept of academic freedom. For it is precisely that commitment to intellectual diversity and the emphasis it has long placed upon individual faculty autonomy that has made it such a challenge to persuade faculty members to look beyond their own courses, see the value of assessing students as a cumulative product of all their educational experiences within the curriculum, and work together to develop such assessments.
How do things get better, then? As a modest proposal, let me suggest the value of separating assessment out of the context of accreditation and linking it instead to that transformational leadership Gawande saw as essential to creating change in the hospitals he visited. College presidents, who are so often called to make declarative statements about the quality of learning on their campuses, are also those best positioned to ask the most fundamental questions about identity and mission and the extent to which the institutions they are stewarding are, in fact, accomplishing their claims. Moreover, and especially on small campuses, it is they who are best placed to exercise the kind of leverage that is ultimately needed to reshape institutional cultures and to conduct the tricky business of persuading the faculty to take on a task that potentially calls for a working in very new ways. In difficult economic times and just two weeks before the peak of this year’s admissions cycle, the challenge of creating a true culture of assessment may well not be the most pressing issue on a president’s mind, but what will best serve their institutions best in the longer term? Just as the treatment of cystic fibrosis shows what could be gained when the resistance to developing and sharing common sets of outcomes data was overcome, so too liberal learning will ultimately be all the stronger for campus leaders who commit to understanding, and disclosing, what truly happens to students on our campuses.
Iain Crawford teaches in the department of English at the University of Delaware. He served as the vice president for academic affairs at The College of Wooster from 2003 to 2009.
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