Mount Auburn Hospital
1997 Annual Dinner, Cambridge, MA

September 9, 1997

Diana Chapman Walsh
President
Wellesley College

"What Has Higher Education to Learn from Health Care?"

I'm very happy to be here tonight for your 15th Annual Dinner. It's always a privilege to join company as distinguished as you've assembled over the years to speak on this occasion. When Frank Lynch invited me, he listed your former speakers and I remember thinking that this was going to be a busy time for me -- right at the opening of college -- but that I really couldn't decline, not only because of what Mt. Auburn Hospital represents in our community, but also because I was honored by your invitation. I thank you for bestowing it on me.

For my topic, I want to reflect on continuities and discontinuities between your world -- health care (which was my world not so long ago) -- and the world of higher education in which I'm anchored now. First, I'll draw some macro-level parallels in the policy landscape and explore what they may augur for the future of higher education, then I'll say bit about the issue of innovation and change (an issue familiar to you) from my vantage point at the helm of Wellesley College.

Health Care vs. Higher Education

We all know -- right? -- that they are worlds apart, these two worlds of ours -- health care and higher education? In health care, it's dog eat dog. In higher education, it's just the reverse. And, in fact, much of the commentary in the press -- more and more -- is advancing the view that the differences are collapsing.

One finds increasingly portentous allusions to health care for higher education. "Watch out," they seem to say, "You're next. It's your turn now for a massive shake up and forced restructuring." Some go on with an even sharper edge, "and none too soon," they say or imply, "everyone else has had to down scale. You'll deserve what you get. You're slothful, smug, and slovenly."

I heard a radio broadcast of the McLaughlin Group on Friday night, and the venom directed at the leadership of higher education took my breath away. Much of the language was eerily evocative of the critique that began to mount against health care in the 1970s. Shouted allegations -- of fraud and abuse, of arrogance and unearned privilege, of eroding quality, flaccid leadership, rank incompetence -- were being flung about self-righteously, with no attempt at grounding them in anything like a cogent argument.

All of this is of course quite unnerving -- to us as it was to you. We ask ourselves what it means for the future of institutions that we know in our bones are essential to our nation's continued success in the world, indeed to the safety of the world. As was true when health care first came under this style of attack, education is without question a major source of solutions to problems we as a people face.

To health care we look for solutions to the aging of our population, the widening gap between rich and poor, the explosion of technology, and the biological revolution -- how to translate the stunning accomplishments responsibly and humanely into improvements in health and the quality of life, how to distribute them with some semblance of equity and fair play ... minor questions like those.

In the case of higher education, as our world economy moves us through a rapid and revolutionary transition from the post-industrial era to a knowledge era and to the third millennium, paradoxically, it's the very importance of what we offer that makes us such an enticing target for criticism, a lightning rod for our society's collective fears and insecurities about the future, as health care has been for three decades at least.

Higher education, we know, is:

• one of this nation's highest-quality and most manifestly successful export products;
• the engine of social mobility essential to our democratic ideals;
• the nidus for new discoveries that are (for example) taking us to Mars and beyond; mapping the genome and dramatically extending healthy life; making ever smarter machines to simulate and extend the human brain; on and on;
• the bulwark and transmitter of our nation's core values and self- understanding, traditions, historical imagination, aesthetic sensibilities, cultural treasure;
• the unique venue in our country where people of astonishingly diverse ethnic, racial, geographic, national, and socioeconomic origins come together and learn not only to coexist but actually to create hopeful communities;
• all of that and more ...

It's the fundamental importance of our two industries, importance socioeconomically, politically, symbolically, practically -- the high expectations society has of us, and we have of ourselves -- that makes us both increasingly expensive and increasingly vulnerable to charges that our costs are unacceptably high. If we didn't matter so much to so many people, our costs would be our own business, and (as you in health care know better than most), our costs are everyone's business, more and more.

In health policy, in the '70s, we taught our students that the big-three policy variables were access, quality, and costs. One of my colleagues in public health spent one whole summer learning how to juggle so he could come into class in the fall and demonstrate vividly for his students that the trick in health policy is to keep those three balls -- access, quality, costs -- in a kind of dynamic equilibrium.

In higher education, the strident quality criticism came first (the harsh critique characterized by books like The Closing of the American Mind, ProfScam and many others). Attention has shifted for now to the twin problems of access and costs. But we can be sure that where there are concerns about money, questions about value for money are not far behind. That's certainly one lesson we can take from your experience.

The big three policy variables do have to be juggled. In higher education, as in health care, the industry's stability and social legitimacy will depend on how effectively it can meet these three conflicting social desiderata:

• providing widespread and equitable access to a college degree through financial aid and a flexible menu of alternative payment options, timetables, and points of entry into the system at a time when demographics and a less forgiving job market are swelling demand, while politics and resentment are shrinking public support;
• maintaining the quality (and the perceived integrity) of the educational enterprise and demonstrating the value added, in the face of withering attack; and
• managing the costs, or at least making a convincing case that they are indeed justified, that the product is being delivered as efficiently and effectively as possible within the constraints of access and quality.

Keeping these three goals in balance is increasingly difficult because of the myriad social pressures we all face, the outside forces with which our two industries are grappling in different ways -- demographic changes, information technology, globalization, the knowledge explosion, changing public expectations, to name just a few.

The clear parallels between our two sectors of the national economy raise deep questions about changes in store for higher education -- how much of what changes are needed to accomplish what ends, what changes would be counterproductive, and, oddly, whether any of us have the power to forestall changes for the worse, given the sociopolitical and economic environment in which we find ourselves.

We in higher education watch what has happened to you in health care and wonder whether some sort of revolution is afoot for us. Sam Thier likes to quote George Richardson's comment that he grew up secure in the knowledge that there were three enemies with which to contend -- Soviet communism, Yale University, and the Peter Bent Brigham Hospital, Now, only one remains. That sounds like a revolution.

The one that remains, of course, is Yale, and that may say something about the durability of the university as an institutional form. In fact, Clark Kerr, former Chancellor of the University of California, liked to point out that if one goes all the way back to 1520, the dawn of the Reformation, one finds about 85 institutions that still exist today, more or less in the same form and serving largely the same functions: the Catholic Church, the parliaments of Iceland, Great Britain and the Isle of Mann, a handful of Swedish cantons, and about 70 universities. But complacency is always dangerous and at this poignant moment, when the British monarchy (that bulwark of Anglo-Saxon stability), is being shaken to its core, one is reminded how vain and foolish we would be to play King Canute, trying to hold back the waves.

And yet, to continue the allusion, Diana, Princess of Wales -- for all her struggles -- captures the imagination in part as a reminder that we don't have to conspire in our own diminishment, a lesson we Americans learned also from the simple decision of Rosa Park no longer to sit in the back of the bus. Some changes we have to accommodate, some we should stand and fight. The grace we need is to discern the difference. Let me be a bit more specific and offer you a perspective on change at Wellesley College, as we've been thinking about it.

Change at Wellesley College

We've been thinking about it a lot, about innovation at Wellesley, much to the irritation, I sense, of some of the faculty, who feel, with Ogden Nash, that "progress may have been all right once, but it has gone on too long." Nevertheless, I've been pushing our college community to engage the issue of change, and when we do, we surface a powerful tension between two institutional self-conceptions that seem fundamentally at odds:

• On the one hand, we experience ourselves as an institution that has changed and is changing all the time (the faculty in particular, espouse this view);
• on the other, we worry that we may be risk averse, stuck in governance systems and structures that stall or stifle innovation (it's the trustees, principally, who give voice to the concern that our strategic environment is changing faster than we realize).

We've struggled with these questions in many discussions on the campus over the past several years, and there's truth in both perspectives. Does Wellesley change? Absolutely. The College has become, in just the past 10 years, a dramatically different institution from the one it was a decade ago - - more interesting, more varied, more relevant and forward-looking.

We've seen extensive diversification of the curriculum. The faculty are constantly adding to their courses new material from other countries and from other cultures and from new research. The Shakespeare course is going strong (despite allegations to the contrary), but it's dramatically more interesting and complex, infinitely more intriguing, than the course I took at Wellesley 30 years ago. You wouldn't know that by reading the catalogue.

Many of the changes in courses and departmental curricula have gradually breached departmental boundaries -- in search of insights at the interstices -- and evolved into new intellectual domains like Technology Studies, Women's Studies, Jewish Studies, Japanese and Chinese Studies, Computer Sciences, Psychobiology, a Writing Program, a Quantitative Reasoning requirement, etc.

All of those programs have been added at Wellesley in the past 25 years, and at most highly-selective liberal arts institutions. And, as you'll readily deduce, the great expansion of knowledge and scholarship stretching the curriculum is one of the engines driving our costs much faster than general inflation.

Interdisciplinary collaborations and team teaching are proliferating, too, with the knowledge explosion. If we had video cameras in the classroom, we would see palpable changes in teaching styles -- more interactive, flexible, and inventive teaching, more attuned to students who have grown up in a complex visual culture, with different learning strengths and needs. We're spending a fortune, it feels, on instructional technology.

We've achieved significant diversification of our student body. Fully half of students at Wellesley today represent categories other than the white, native-born citizens of the U.S. who used to define and shape the institution, and they span a much wider spectrum, socioeconomically and in terms of age. It may surprise you to hear that US News & World Report announced the other day that Wellesley has the most diverse student body of any college outside of California and the fifth most diverse in the nation.

This presents us with unusual opportunities and obligations, as I've been saying on campus, to step up to the intellectual challenges embedded in our growing national diversity, challenges, I believe, the academy as a whole has yet fully to embrace. My hope is that we at Wellesley will become eloquent and passionate about the mix of knowledge, skills, and sensibilities today's students most need for effective citizenship in our changing world of shifting boundaries and identities.

Part of our challenge is that our student body changes far more rapidly than do our faculty and staff; roughly a quarter of our students turn over every year at Commencement, while the turnover rates for our staff and faculty are 8% and __% respectively. A substantial proportion (51%) of the faculty are tenured, for good or ill (and you know there are strongly-held views on that loaded topic).

I won't venture far into that lion's den, but suffice it to say for now that it is some of both (good and ill), without doubt a stabilizing force within our community (our extraordinarily gifted, loyal and committed faculty is our sine qua non, just as your medical staff is yours). Tenure is an indispensable recruiting tool for us (we can't afford the salaries you pay), but it's also a barrier to rapid change. Still, our faculty is increasingly diverse and increasingly attuned to a wide range of cultures and alternative viewpoints, the purpose of diversity in the academy, as my colleague Neil Rudenstine argued elegantly in a recent president's report.

Our endowment has grown dramatically, and that's certainly good. We've built new facilities that have redefined the way we use the campus: a sports center, a museum, a co-generation plant, a science center with equipment few undergraduates elsewhere see. Those capital improvements have driven up our operating costs, a phenomenon of which you are in health care all-too-familiar. When we weren't juggling in the old health policy courses, we were quoting Roemer's law about the ongoing operating costs of a hospital bed, once built, whether or not it was occupied.

We make far greater use of technology now -- for good or ill -- again, some of both, but it's a sea change nonetheless, a sudden and dramatic one. Every dorm room is wired to the ethernet, a "port for every pillow," we say, determined as we are to provide women at Wellesley not equal opportunity but every opportunity, in technology and across the curriculum. This ethic of comprehensiveness in the liberal arts ideal is, of course, expensive, increasingly so as the universe of opportunities continues to expand.

There's much more we want to do, of course, there always is. For the year ahead, we already have a number of initiatives under way, an even dozen to be exact, designed in aggregate to weave together many strands of institutional self-assessment, reflection and planning laid out in recent years, draw them together into a synthesis, pool and test what we know and understand to be our strengths, vulnerabilities, opportunities and obligations as we approach our 125th anniversary, which we'll celebrate in the year 2000.

We'll be examining -- to give you some flavor of the initiatives -- the evaluation and development of teaching; global education; instructional technology; experiential learning; interdisciplinary and interdepartmental programs; the first-year experience; multiculturalism; student life and the organization of student services; the religious and spiritual dimensions of education; stewardship of our budget and our campus -- both the buildings and the grounds.

We invested $150 million over the past decade in our extraordinary campus, widely recognized as one of the great built landscapes and an irreplaceable asset not only for the college, but for the greater Boston area and for our 30,000 living alumnae all over the world. Maintaining our 800 acres is an increasingly expensive proposition, and we've just initiated a master planning process to look out over the next twenty years. If you're interested in landscape architecture, keep an eye on our programs this fall; we've planned several public exhibitions and events to coincide with and inform this campus planning work.

The theme that unifies these several strands of work is a recommitment to our long-standing record of intellectual excellence as we reckon with forces of change. We are calibrating how we should adjust our priorities to ensure that we continue to provide a rich and rigorous educational environment that is self-conscious and effective in developing the whole student.

From this perspective, I hope you'll agree, Wellesley College is an institution that does embrace change, does continuously incorporate improvements into the fabric of what we do. That's one side of the paradox. On the other side, as I've said, we've been chiding ourselves for being risk averse and resistant to change.

At a four-day conference we held on institutional change not long ago, this was a powerful theme. If we're not in financial trouble, one faculty participant asked, why would we want to change? The old Chinese curse, "may you enjoy 20 years of success," was invoked by a trustee participant, and another faculty member called our current position of "privilege" "one of our great difficulties now," and a formidable barrier to the successful management of change. "We are addicted and comfortable at the top," another faculty participant asserted ... "fearful of losing ground." Another observed that the pace of change outside Wellesley is increasing faster than the pace of change within; "the gap is widening," he said.

Which is it then? Are we continuously regenerating ourselves, or are we stuck? Is it excruciatingly difficult to lead a process of institutional renewal and change at our colleges and universities? The answer is yes, and no. It all depends ... on the kind of change -- whether it's local or more universal, whether it's immediate or longer-term.

If my reading of our history is right, then we've been doing rather well at local, incremental change. It's happening all the time and it is renewing the institution; we're not standing still, we're not stagnating. Where we experience more trouble is when we try to assemble the political forces for a high-visibility institutional-level change, whether short term or long term, a "restructuring" to use the current buzzword. That's where we come a cropper of the impressive bulwarks that have been built in academia to protect the status quo.

And our concern about our ability to catalyze institutional-level change exacerbates the worry about the longer-term future of higher education. Are we adequately prepared for threats we see on the horizon? How will they affect us? Will we be agile enough to respond expeditiously? We know we need to work very hard on several fronts to improve the quality of the education we provide and to increase the efficiency and effectiveness of our operations. But do we see a revolution coming?

Differences Between Health Care vs. Higher Education

This is where the comparisons with health care often come in, as a cautionary tale for higher education. I spoke of some similarities and now I would like to draw out some essential differences. Health care was a cottage industry 20 years ago, loosely-coupled referral networks of solo, fee-for-service practitioners and a patchwork of hospitals with overlapping service areas and conflicting and murky missions, as well as elaborate third-party payment arrangements and cross-subsidies that produced all the hallmarks of market failure. Beginning microeconomics courses used health as the model for market failure, and Paul Ellwood, who liked to be thought of as the father of the HMO, used to say that the problem with the health care delivery system was that it wasn't a delivery system at all; you had to go pick it up.

Higher education is in a different place, it seems to me. It is not a unorganized cottage industry in which great efficiencies can be achieved in the delivery of the same basic service by a rationalization and restructuring of the overall system, not nearly as dependent on third-party payment (I'm speaking now of the private institutions).

And -- before the chance to prepare tonight's talk made me re- examine some of my assumptions -- I might have argued that aspects of the governance of higher education are dramatically different from health care. Now I'm not so sure.

It's my belief that the primary obligation of leaders of educational institutions is to do all we can to hold open a space in which a community of growth and self-discovery can flourish for everyone. The president of a college or university -- no more nor less, I'm sure, than a hospital CEO (I've known a few very well) -- is constantly beset and besieged by a cacophony of competing claims for resources, attention, validation.

The criteria for adjudicating these varied and competing claims are much more fluid and debatable than is the efficiency test many organizations can apply almost by rote. But in a community of learning, I believe, that debate over values and vision and direction is an essential part of the educational process, part of the rough and tumble of a learning environment that prizes its participatory governance system. In education, the process is inextricably bound up with the product. Learning is nothing if not a process of discovery and unfolding.

That means that how educators do our work -- where we put our emphasis, what values we embody and express, who we consult, when and how, how we respond to the relentless pressures of time, projections, expectations, conflicts -- is nearly as important as the outcomes we actually seek to produce.

In fact, the process is the outcome in a perverse sense. We teach as much by the example of what we do, and how we do it, as by what our professors actually profess in the classroom. We create an environment though our leadership -- as we do also in the design of our buildings and grounds -- and those environments that we create are part of a powerful silent curriculum we teach that is not documented in the catalogue.

Now, I might have said that health care is different in this respect, that you need to get a job done as efficiently and effectively as you can, that the quality and style of leadership are secondary concerns, appropriately take a back seat in this utilitarian frame in which you find yourselves. But I wonder.

In a Falmouth nursing home a sign greets you at the door. It says, simply, "kindness heals." At the department I led at the Harvard School of Public Health, we had a keen interest in social relationships and health, in mounting evidence that the right kind of social support is an independent variable that directly affects health outcomes. My successor at Harvard, Lisa Berkman, has done classic studies in this field.

If the human touch is this important, then I think we might agree that the quality of leadership -- as it affects organizational culture and design -- may be as inextricably bound up in the possibility of success in health care as is the case in higher education.

Coming to terms with the importance of process, of how we do our work, is a humbling realization for we all have our imperfections, inconsistencies between our expressed aspirations and our performance. Those of you who have raised children won't be surprised to hear that our students are quick to call me to account for our imperfections and inconsistencies.

The good news is that human creativity arises in just this gap between vision and reality, in the disquieting but galvanizing structural tension we experience between where we are and where we aspire to be. Holding that tension in active consciousness is the first step in the creative act.

Creativity is stifled when we paper over the tension with self delusion about where we are or, conversely, when we lower our ambitions rather than tolerate the tension. Creativity requires the confidence to grant what one may not know, demands the courage to look failure in the face.

Holding that tension is one of the most excruciatingly difficult jobs of a leader. Standing in that place -- between the vision and the reality -- creating and holding a larger space capable of encompassing them both -- is a key task of leadership, and one of its great existential and personal challenges. There's much more to say about all of this, but there isn't time. Instead, let me leave you with an image as we close. It's a sort of parable that I heard years ago at a seminar on planning for change -- maybe you've heard it.

It begins with a large ship steaming, full throttle, in the dark of night, when the captain, on the bridge, spots a light ahead through the fog, directly in his path. Alarmed, he sends a message: "Change your course 15 degrees." The answer comes back, tersely, "Change your course." Irritated, the captain replies, "change your course, I'm a captain." The response this time is "Change yours, I'm an ensign." Now the captain is furious. "Change your course, dammit," he signals, "I'm a battleship." "Change yours," comes the reply, "I'm a lighthouse."

Distinguishing the movable from the immovable obstacles will take all the wisdom we can muster. We in higher education are grateful for the guideposts we can find from the examples you are setting in health care. In both sectors there is much at stake for our nation and our world. I'm grateful to the Mt. Auburn Hospital for your palpable commitment to human values as you confront the forces of change. I wish you calmer waters in the years ahead. Thanks very much for having me here and for hearing me out.