GOVERNING BOARD DECISION MAKING: ESTABLISHING A COLLEGE OF MEDICINE By Kathleen Melinda Wilbur A DISSERTATION Submitted to Michigan State University in partial fulfillment of the requirements for the degree of Higher, Adult, and Lifelong Education – Doctor of Philosophy 2018 ABSTRACT GOVERNING BOARD DECISION MAKING: ESTABLISHING A COLLEGE OF MEDICINE By Kathleen Melinda Wilbur Higher education governing boards have existed at colleges and universities since the first institutions opened during the 1600s in the U.S. Despite all the major changes that have occurred in higher education resulting in very different institutions being developed and opened governance has remained much the same since the first colleges and universities were opened. Yet during the past few decades many events and influences on campuses have required governing boards to be more involved and engaged. Therefore, having a better understanding of how boards reach decisions is very important to appreciate and understand. Governing board decisions are made about a large variety of topics and may be small, perfunctory, or have significant impact and have long term effects on an institution. Identifying and understanding how board members are able to interact with each other and then with the university they serve, to discuss, debate and make any of those decisions is a challenge. This study focused on governing board decision making that led to the establishment of a college of medicine at a comprehensive university. Governing board members and administrators were interviewed and board documents were reviewed to gain insight into how the board studied, deliberated and ultimately reached a decision about establishing a new college and the initial steps followed to begin implementation once the decision was made. This specific case study allows for some conclusions to be made about governing board decision making in general. Copyright by KATHLEEN MELINDA WILBUR 2018 I dedicate this dissertation to my husband Tom and our four sons – Tom, Will, Sam and Ray Wilbur. Every one of them provided continuous support, in one way or another, of my work throughout my doctoral program and the writing of this dissertation. iv ACKNOWLEDGEMENTS When I began my doctoral program at Michigan State University, I had no idea so many would help guide and encourage me throughout my schooling and the writing of my dissertation. My husband Tom always respected the time and energy I needed to dedicate to my work and insured distractions were kept to a minimum. His encouragement, along with the encouragement from each of our sons, kept me going and allowed me to successfully complete my program and this dissertation. My academic advisor and dissertation chair Dr. Marilyn Amey helped keep me focused and on track. From the very beginning I knew I was fortunate to be able to work with someone with her background, expertise, drive and consideration. She seemed to know when to allow me to pursue an idea and when to redirect me but always with kindness and respect. I doubt my work would have been completed without Dr. Amey’s guidance and direction. Dr. Steve Weiland was a favorite professor and I took every class with him that I could. He challenged me to think in new ways and to apply that thinking to higher education issues as well as others. I will always remember the guidance Dr. Weiland provided throughout my coursework and especially in preparing for my comprehensive examinations. I have also been extremely fortunate to have Dr. Roger Baldwin as a faculty member. From the course work in his classes I also began to better understand and appreciate research. Dr. Baldwin and I had the opportunity to conduct long-term research on governing boards which has been published and about which we have made presentations. He helped me understand the purpose and finer points of research and writing, and challenged me to more clearly and efficiently express myself when presenting study results. v Dr. Celia Guro served as a member of my dissertation committee even though her professional responsibilities were extremely demanding in her home college. Her insights, questions and comments throughout my dissertation process were thoughtful, and helped improve my writing and allowed me to better present my ideas and conclusions. Her encouragement throughout my program and dissertation was always offered at the right time and helped me complete my work. As I considered pursuing a PhD, my friend, Mike Zeig always seemed to know the right thing to say or provided the right answers to my questions. Once I applied and was accepted into the HALE program Mike was always generous with his time and his counsel, and read and helped edit more draft papers and reference sections than he ever expected to. In truth, Mike served as a mentor to me throughout my program. Drs. Zeig and Baldwin both helped me learn how to become a researcher when we collaborated on the trustee study. Each one of us brought an expertise to that process that enhanced the study. I am grateful to both of them for allowing me to work with them and hope our work continues in the future. I am also appreciative of the members of my HALE cohort who always challenged me and helped improve my work with their advice and counsel. Charla Miller and Angie Armstrong deserve recognition and my gratitude. Their patience and guidance helped solve many of my logistical and technological challenges. Without their assistance this dissertation probably would not have been completed. vi TABLE OF CONTENTS LIST OF TABLES ix Chapter One: Introduction Significance of Studying Governing Board Decision Making Theoretical Frameworks Applied To Decision Making Governing Board Study Experience 1 3 5 7 Chapter Two: Literature Review State Comprehensive Universities State Comprehensive University Governing Boards Colleges of Medicine Comprehensive University Colleges of Medicine Decision Making Processes Governing Board Decision Making Relative to Mission and Resources Theoretical Frameworks 9 9 12 13 17 18 19 22 Chapter Three: Study Methodology Methodology Site Selection Study Participants Data Collection Data Analysis Qualitative Study Trustworthiness Role of Researcher Limitations 28 28 30 30 31 33 34 34 35 Chapter Four: Board of Trustee Findings Governing Board Service The Idea: A College of Medicine Filling the Information Vacuum Feasibility Study The Medical School Vision Committee Ad-Hoc Medical School Committee Additional External Report Other External Sources Considering the Data Decision Leader The Medical School Decisions A College of Medicine: Why? The Decision Making Process The Decision in Retrospect The College of Medicine That Almost Wasn’t 37 37 39 41 43 46 47 48 49 50 51 53 54 55 57 60 vii Chapter Five: Administrator Findings The Idea: A College of Medicine Administrators and the Board of Trustees Internal Data Gathering External Information Gathering How Did the Board Work Together? Decision Leaders Reasons for the Decision Decision Making Process Lessons Learned 62 63 65 65 67 70 70 72 73 74 Chapter Six: Discussion of Board of Trustee and Administrator Findings Stewardship Theory Strategic Choice Theory Socialization Theory Reaching a Decision Influential Factors How the Board Sought Input Whom Did the Board Consult? 76 78 80 82 83 84 85 86 Chapter Seven: Conclusions Implications for further study Summary 88 93 97 APPENDICES APPENDIX A Interview questions for former Board of Trustee members APPENDIX B Interview questions for university administrators 98 99 REFERENCES 100 101 viii LIST OF TABLES Table 1: Three Theoretical Frames 27 ix Chapter One: Introduction This study analyzes how public higher education governing boards consider and make decisions about establishing new professional colleges at their institutions. Typically, governing boards are either appointed by a Governor or a state legislature or are elected with a mandate to represent the public good (Floyd, 1995) when making decisions about their institution. Even so, scholars such as Kerr and Gade, Chait, Holland and Taylor and Kezar differ in their views of governing board roles. Kerr and Gade offer a traditional view of public university boards indicating their role is to serve as “guardians of a broad public interest rather than as servants of a more narrowly defined political constituency” (in Floyd, 1995, p.96). Comparatively Chait, Holland and Taylor almost diminish the role of governing board members by suggesting, “trustees are often little more than high-powered, well-intentioned people engaged in low-level activities” (1996, p.1). Kezar (2006) suggests a broader view of board responsibilities including hiring and evaluating a president, establishing and eliminating programs, serving as financial stewards of the organization and protecting the university mission. Carver (2013) is more succinct and posits that governing boards typically focus on internal university matters such as personnel, fiscal issues or logistics. Couple these different views with the Association of Governing Board 2010a survey which indicates that only 15.5% of elected or appointed trustees have any professional experiences in the education sector. Most trustees have very limited training in how colleges and universities operate so they rely upon their institutions to educate them (Miller, 2011). With such divergent views and opinions of board duties and responsibilities and limited educational experience besides their own schooling it is difficult to understand how boards perceive their roles and are able to identify ways to work with other board members and 1 university administrators and make decisions on behalf of their institutions. Universities should embrace and accept some responsibility to educate board members. However, the public must be watchful to insure that board members remain objective and do not become rubber stamps for university proposals that without governing board oversight and monitoring could occur. Some observers argue that as universities have evolved so have board members who today bring different observations and perspectives (Gayle, Tewarie & White, 2003) to the board table often the result of their professional backgrounds and experiences. Kezar and Eckel (2004) suggest these board member changes have led to increased tension between universities and their governing boards about what a board’s actual function is in higher education governance. Bastedo goes so far as to imply in some cases there is a moral seduction of board members who “believe more in the fundamental rightness of their own judgments than in the organizational mission constructed by others” (2009, p.359). He contends board members may prefer their own judgments over others because they overestimate the value of their own experience and diminish the value of other’s experiences. Mortimer and Sathre (2007) are derogatory when they contend that today’s governing boards are either “out-to-lunch” or managerial boards that deal only with university administrative issues. Increased tensions and uncertainty about the appropriate roles of university administrators and their governing board members suggests that decisions to be made by boards might be unresolvable or result in stalemates. While that could occur on occasion, it does not appear to be the norm in higher education governance. Understanding how boards and university administrators navigate their relationships in order for governing boards to resolve issues and make decisions such as those relative to admission policies, a university budget, tuition, campus master plans and others is valuable to know. But rather than examine standard governing board 2 decision making this study analyzes how a public higher education governing board considers and made the specific decision to establish a new professional college of medicine at its institution. Hence, the study was guided by the following research questions: - What factors influenced board member decision making? - How did board members seek input when considering this proposal? - Who did board members seek input from when considering this proposal? This in-depth case study of governing board decision making can be useful in the future to other governing board members, administrators, faculty, staff and external constituencies. Significance of Studying Governing Board Decision Making Governing boards have existed at colleges and universities since they began in the U.S. in the 1600s (Thelin, 2011) and it is likely these governance structures will continue to exist. The Association of Governing Boards (2014) suggests that despite all the change occurring in higher education today governance is still approached the same way it has been during the past 50 to 100 years. However, studying governing boards and decision making is challenging because there is limited attention paid to board governance in higher education literature (Slaughter, Thomas, Johnson & Barringer, 2014; Kezar & Eckel, 2004). Bess and Dee interpreted Brehmer (1999) who asserted that “despite nearly 50 years of decision research, we do not know much about what people actually do when making decisions” (p. 10) including university boards of trustees. Meanwhile recent events on a variety of campuses reflect actions taken by more engaged, and some suggest intrusive governing boards so understanding how boards reach decisions is even more important to appreciate. An example of such a far-reaching and quickly made decision was the removal of President Teresa Sullivan from the University of Virginia in 2012 3 by board leaders because they felt she was not following a strategic plan to introduce more online education at the university (Rice, NYT, 2012). After much uproar from faculty, students, alumni and external constituencies, Dr. Sullivan was returned to the role of President of UVA. In another example of trustee overreach the governing board at Sweet Briar College in 2015 announced the closure of that institution. College alumni and faculty argued the decision was made without enough internal and external input. That decision was also then quickly reversed (Szkotak, The Huffington Post, 2015). Both these examples help illustrate the impact boards can have at their institutions (Stripling, 2015; Marcus, 2015). Such examples suggest the more traditional and long-established roles of governing boards are being challenged more frequently by currently serving board members. Considering the changing characteristics of governing boards along with the challenges facing comprehensive universities today which include enrollment pressures, changing student populations, limited financial resources, external pressure to more quickly eliminate or add programs to meet public needs, interpreting the impact and importance of globalization and of new technologies, a better understanding of how boards make decisions becomes critically important. Those decisions will greatly influence what higher education looks like and how it operates in the future. Even in 1983 Chaffee asserted that “college and university administrators tend to devote their attention to a problem situation and its solutions – the substance of a decision – and to forget that achieving a satisfactory outcome may depend heavily on the process by which they reach a decision” (p. 77). More recently Potter and Phelan (2008) argued that most boards consider only the issues directly in front of them instead of thinking long term and strategically. My study of how a board decided to establish a new professional college at its institution should provide important insight into how governing boards function. Understanding 4 decision making relative to one example can provide a useful context for boards and universities to consider when approaching boards about a variety of issues. Decision making is at the core of a university board’s responsibilities. Decisions made may be small, large, perfunctory, impactful or inconsequential but board members must be able to identify a way in which to interact with each other and the university to discuss, debate and ultimately reach a conclusion when presented with an issue requiring a decision. Decision making has been defined in many ways. Mintzberg (1979) asserts that decision making is a process of “developing a commitment to a course of action” (p. 58). Huber (1986) posits that decision making is a process of problem solving that leads to evaluating possible solutions. Typically, governing board decision making would be necessary to either solve problems or establish courses of action or both. The seven roles of a governing board identified by Mintzberg (1983) included selecting the chief executive officer, exercising control during times of crises, reviewing decisions made by management and their performance, interacting with external constituencies where they may have a role in philanthropy, building relationships and funds for the institution, building the university’s reputation and providing advice to the organization. These board roles are simplified by Zahra and Pearce (1989) when they posit that boards have three interrelated roles – setting strategy, controlling the organization and providing service. Again, whether complex or more simplified, these duties and responsibilities cannot be achieved without decision making by governing boards. Theoretical Frameworks Applied to Decision Making Theoretical frames provide an important lens through which to study university governing board decision making. Bess and Dee (2008) posit that theories are important tools for leaders. Theories are based on long term scientific study and provide better informed and 5 “accurate guides to policy and practice than relying on guesswork, intuition, or seat-of-the-pants judgments” (p. 466). Utilizing theories reminds leaders their problems truly are not unique to them or their institutions, and they can benefit from understanding similar situations, problems, and challenges that have occurred elsewhere and resulted in the development of practical, applicable theories. Bastedo (2006) asserts that as higher education continues to develop and evolve more research will be conducted on its policy, its governance and at times the politics of higher education. No doubt in the future more theories will potentially be applied to better appreciate these areas, and they will likely come from the fields of political science, sociology and organizational and business theory. Boards are places where “internal and external coalitions” meet face to face according to Mintzberg (1983, p.103). Going the next step Hung (1998) concludes that a board’s structure and roles are the result of power politics based on a complex network of power relations. Board engagement is complex so it is likely that one theoretical perspective could not adequately provide an appropriate frame for analysis. Thus I considered a variety of theories to apply to governing board decision making including institutional (Bastedo, 2009), principal/agent (Caers, DuBois, Jegers, DeGierter, Schepers, & Pepermans, 2006; Muth & Donaldson, 1998), advocacy coalition (Weible, Sabatier, McQueen, 2009), strategic choice (Bastedo, 2006; Child, 1997), stakeholder (Brenner, 1993), social network (Valente, 1996), stewardship (Drezner & Huehls, 2014; Miller & LeBroton-Miller, 2006; Muth & Donaldson, 1998), and socialization (Nahapiet & Ghoshal, 1998). My conclusion is that a combination of stewardship, socialization, and strategic choice theories are the most applicable theories when analyzing board decision making. I analyze these theories in greater detail in the next chapter. 6 Governing Board Study Experience Studying board decision making is a natural outgrowth of a governing board study I conducted during the past three years with other researchers about recent gubernatorial appointed university trustees in Michigan. They were studied to discern what experience they brought to their board position, what they viewed as their responsibilities as board members, and how they expected to carry out those responsibilities. During this longitudinal study board members participated in three interviews throughout their first three years serving on a board. Following those interviews and analyzing the data, three reports were compiled and shared with participants and other interested parties. The study conclusions are illuminating. Many board members are alumni of the institution they now serve as board members. They are often in leadership or managerial roles in business, industry, and not for profit organizations. They are interested and supportive of their institution’s mission, but they are concerned about duplicative academic programs across higher education institutions, student graduation rates, job placement rates, the impact of online education, tuition and enrollment management. By their own admission board members are unfamiliar with university shared governance structures, why they exist, and how such governance input should be considered. The board members interviewed understand their oversight roles but have generally determined they are in charge of the university with the president as their agent. Recommendations from the study include identifying ways to acknowledge and respect the important role boards serve, providing a comprehensive orientation for new trustees with a focus on shared governance and interaction with faculty leaders along with ongoing educational opportunities for trustees while they serve on the board, maintaining transparent communication 7 with presidents and members of the administration and encouraging boards to regularly assess and evaluate their own performance. The study with newly appointed governing board members provided insight into how appointees initially perceive their board roles and responsibilities. My current study of governing board decision making is an appropriate next step in analyzing how governing boards do consider issues and make decisions about complex issues such as establishing new professional colleges at their institutions. 8 Chapter Two: Literature Review Universities are complex organizations whether they are community colleges, research institutions or comprehensive universities. In order to manage these entities decisions of varying degrees of importance must be made weekly, daily, hourly and sometimes moment to moment. This study analyzed how a comprehensive university governing board considered and ultimately made a decision to establish a college of medicine at their institution. The following sections provide context and background on factors that impacted that decision making process including defining state comprehensive universities, their governing boards, U.S. medical colleges and medical colleges located at comprehensive universities, decision making processes and how governing boards embrace them and the theoretical frames that provide a lens through which to study higher education governing board decision making. This study attempted to unpack how a decision of this magnitude is made by a volunteer governing board of a complex organization. State Comprehensive Universities Since this study focuses on a comprehensive university that decided to establish a college of medicine with governing board support, it is important to understand the history and characteristics of such institutions. According to Henderson (2009), state comprehensive universities (SCUs) are four-year institutions of varied sizes, located in suburbs, towns, cities and in rural communities across the U.S. The American Association of State Colleges and Universities (AASCU) indicates campus enrollments range from 800 to more than 60,000 students (2015). Comprehensive universities offer a large variety of undergraduate and some master's and doctoral degree granting programs. “The very term comprehensive suggests the enlarged form of offerings in these institutions” (Youn & Gamson, 1994, p. 190). SCUs also 9 engage in and encourage students to engage in public service. Additionally, these institutions are committed to making higher education more accessible to students with various levels of preparation. Numerous authors have questioned the role of comprehensive universities including Birnbaum who 30 years ago noted that comprehensive universities were, "relatively invisible, understudied and not always understood or appreciated by legislatures, potential students and other internal and external constituencies” (1983, p. 58). Ten years later, Youn and Gamson (1994) commented on the "difficulty of locating these entities on the institutional map of American higher education" (p. 190). They argue that even with rapid enrollment growth and a significant expansion of academic programs there is still uncertainty about the institutional purpose of comprehensive universities (1994). Higher education literature often refers to SCUs as “muddled characters’ searching for their place in the institutional hierarchy (Clark, 1987). Despite these views Finnegan asserts that comprehensive universities are institutions that “hold the promise of social mobility for attendees and a better life than the one left” (1991, p. 50). Additionally, Henderson posits that SCUs may be the most under-appreciated higher education institutions even though they educate a significant portion of American college students. This least understood higher education sector is interesting when considering the numbers. Of the approximate 4,000 public and non-profit higher education institutions in the U.S., there are nearly 1,000 SCUs granting o n e- half of all bachelor and master’s degrees awarded in the U.S. (AASCU, 2015). Attendance at SCUs began to grow substantially following the conclusion of World War II when there was a flood of military veterans who when they returned to America received federal government support through the GI bill to pay for a college education (Geiger, 2005). All university sectors experienced an enrollment 10 increase as a result of this influx of students. However, following that ti me period SCUs continued to experience substantial enrollment growth throughout the 1950s and 1960s. In 1954 state comprehensive universities across the US enrolled 299,000, and by 1966 those enrollments had increased to 1,300,000 (Henderson, 2009). In 2015 AASCU reported that SCU enrollments totaled nearly four million students representing 46 percent of all students at public four-year colleges and universities and 28 percent of all students attending all public and private four-year colleges and universities (2015). With SCU enrollments and degrees granted increasing, it is still challenging to explain the under appreciation of SCUs. In part, comprehensive universities share overlapping purposes with other institutions such as community colleges, research universities and liberal arts institutions. While there is overlap in undergraduate curriculums offered, comprehensive universities are recognized as being more accessible to a variety of students and are more affordable than research or elite institutions (Finnegan, 1991). Due to their accessibility, affordability, diverse curriculum offerings, and commitment to public service Henderson (2009) refers to comprehensive universities as the People's Universities. Originally, many SCUs opened as teacher’s colleges, but when an influx of students occurred they broadened their mission and added more academic programs with a vocational focus (for example, engineering, bio research, technology and health care fields) along with some research and public service components (Geiger, 2005). An understanding developed that SCU programs were “designed to prepare students for jobs immediately after graduation in fields ranging from teaching to nursing to construction management" (Henderson, 2009, p. 6). The history of SCUs suggests that opening a college of medicine and some other professional degree granting programs would be unusual for a comprehensive university. But as 11 comprehensive universities began offering more vocational training programs in allied health care fields such as nursing, physician assistant, physical therapy, audiology, speech therapy, occupational therapy and others they were recognized for the expertise they developed in these areas along with their high achieving graduates. Comprehensive universities also hired wellcredentialed faculty in these fields with strong internal and external reputations. Another component of the comprehensive university mission is a commitment to public service manifested through both academic program offerings and institutional engagement in enhancing the economic development environment near their institutions and helping address societal problems and needs (Henderson, 2009; Lynton & Elman, 1987). Unfortunately, much of the public service is so localized it goes unnoticed in broader communities. However, many of the academic programs offered at comprehensive universities result in graduates securing positions with an emphasis on public service in health care fields, social work, psychology, teaching and other programs that educate students who then meet public needs. State Comprehensive University Governing Boards With a more thorough understanding of state comprehensive universities, it is also useful to have a better understanding of their governance structures and governing bodies which are authorized to make decisions for the universities they represent. Governing boards and their memberships differ from state to state. Some states have statewide governing boards that make decisions for the public four-year institutions in their state. Others have a multi-campus consolidated governance system that allows for each public campus to have their own governing board. However, their recommendations still require review and approval by the consolidated board. A limited number of states have constitutionally established and 12 autonomous boards for each of their public four-year higher education institutions with the authority to make and implement decisions for their individual campuses (McLendon, 2003). In all instances governing board members are either appointed by the Governor or the Legislature, elected by the public, or selected internally from the ranks of university administrators and/or members of the student body (McLendon, 2003). This study analyzes how a constitutionally autonomous comprehensive university governing board made a decision to open a college of medicine at their institution. Colleges of Medicine Since this study examines how a comprehensive university governing board decided to establish a new college of medicine, it is worthwhile to consider the state of medical education across the U.S. Currently there are 141 long-established or newly accredited allopathic or osteopathic colleges of medicine across the country. These are located within universities or incorporated as free-standing 501C3 non-profit entities (Whitcomb, 2009). However, as recently as 1980 only 127 accredited schools of medicine operated across the U.S. which annually graduated approximately 17,000 physicians (AAMC, 2006). In 1984 the Graduate Medical Education Advisory Committee (GMENAC) in response to a Congressional mandate conducted a four-year study about the physician workforce in the U.S. The report concluded there would be an oversupply of doctors by the year 2000. In reaction to the study's conclusions Congress eliminated any federal support for the expansion of existing medical schools or the development of new ones (Whitcomb, 2009). Consequently, during the late 1980s and throughout the 1990s no institutions established or sought accreditation for new colleges of medicine (Pew, 1995; Schofield, 1984). However, the American Association of Medical Colleges (AAMC) began to receive anecdotal information from across the country suggesting 13 that the reality of an oversupply of physicians was inaccurate. As a result, the AAMC studied physician workforce numbers and projected physician shortages in some medical specialties and in certain geographic areas of the country (Whitcomb, 2009). Following their studies conducted in the early 2000s, the AAMC issued a charge to higher education institutions and health care providers to increase by 30 percent medical school enrollments either at existing schools or establish new colleges of medicine to address the physician shortages (AAMC, 2006). The most recent study commissioned by the AAMC released in April, 2016 indicates a shortage of physicians by 2025 of between 61,700 and 94,700 (Mann, AAMC Reporter, 2016). In Michigan a 4,400 physician shortage is predicted by 2020 (AAMC, 2006, 2012). The 2016 AAMC study specified the medical fields that would experience the highest shortages. By 2025 the shortage of primary care physicians will be between 14,900 and 35,600 physicians. Both specialty and general surgeons are expected to decline with an approximate shortage o f 25,200 to 33,200 surgeons. Specialties including emergency medicine, psychiatry and others also project shortages of between 22,200 and 32,600 physicians (Mann, AAMC Reporter, 2016). The AAMC stands by these data because they help bolster their argument there is a real physician shortage that has to be addressed to meet public needs. According to AAMC President and CEO Darrell G. Kirch, MD, “These updated projections confirm that the physician shortage is real, it’s significant, and the nation must begin to train more doctors now if patients are going to be able to receive the care they need when they need it in the near future” (AAMC Reporter, 2016, p. 4). Not surprisingly physician shortages have occurred periodically throughout U.S. history for a variety of reasons. Several factors contribute to the current and expected future 14 shortages including population growth, the increased life expectancy of baby boomers (considered to be the largest generation of Americans born in U.S. history), the anticipated retirements of a third of the currently practicing physicians and the expected 32 million additional citizens finally able to seek health care as recipients of health insurance under the Affordable Care Act (New York Times, 2010). The typical response to physician shortages has been to increase student capacity by expanding class sizes at existing colleges of medicine or opening new colleges. But according to Richard Cooper, co-chair of the Council on Physician and Nurse Supply, “each time a physician shortage occurred the obstacles of applicants, time and money were encountered” (2003, p. 71). The cost of opening a new medical college for universities is real and significant. Some of the most expensive academic programs are those in the health professions including medicine. According to Emery A. Wilson, MD, a principal at DJW Associates, a recognized medical education consulting firm, higher education institutions considering opening a college of medicine need to identify $100 to $150 million to meet initial operating expenses until other revenue sources such as tuition and research support would be realized by the college (amednews.com, 2010). Costs are high because accreditation standards from the Liaison Committee on Medical Education (LCME) require medical colleges to provide costly clinical space and equipment for students, hire professional teaching and research faculty (often physicians who could make more income in the private sector) and cover the costs of expensive external programs such as residencies and clerkships typically paid for by the college. Additionally, the LCME requires proof from applicant schools they have multiple revenue sources to sustain a medical college for a number of years (LCME, 2006). Unlike 15 medical colleges opened prior to 1980 there is not federal financial support for new medical schools. Instead, revenue sources the LCME considers viable are state support, university resources, health system or hospital support, private support, research and tuition (Whitcomb, 2009). Dr. Wilson explains that universities contend the costs of opening a new medical college are worth it. Comprehensive colleges and universities understand there is a need for more physicians so they can better justify the cost of opening a new college of medicine because the graduates will meet a need in various communities. Additionally, Wilson indicates many young people are interested in attending medical school so the applicant pool is rich with talent. "A lot of private schools have 5,000 or more applicants for a class of 100 students" (Wilson, amednews, 2010, p. 2). Public medical schools have also experienced large numbers of applicants. Cynda Ann Johnson, MD, president and founding dean of the Virginia Tech Carilion School of Medicine in Roanoke suggested the problem is not having enough applicants; it is narrowing down the list for consideration. Even prior to receiving LCME accreditation, nearly 1,700 students applied to be accepted into the college’s first class of 42 students in 2010 (Cooke, 2010). Founding Dean of the Central Michigan University (CMU) College of Medicine Ernie Yoder echoed the sentiments expressed by Dean Johnson indicating the first class of 64 had to be selected from a highly qualified applicant pool of nearly 2,800 (CMUNews, 2014). The physician shortage is verifiable, the public need for physicians is real and the applicant pools for medical school students are rich with talent. Yet, comprehensive universities still need to identify adequate resources of $100 to $150 million to launch important and necessary professional programs such as medicine. 16 Comprehensive University Colleges of Medicine During the past decade, a number of higher education institutions have studied the feasibility of establishing a college of medicine including comprehensive universities. It is especially interesting that comprehensive universities have considered opening professional degree programs since historically that has not been their stated mission. However, despite the significant costs of establishing professional programs, campus concerns, political considerations and other factors some institutions moved forward while others did not. The 14 new medical schools that have opened since the late 1990s and early 2000s are located across the country and at a variety of institutional types. In today’s challenging collegiate environment, why would a comprehensive university decide to open a medical college? During the last decade of the 1990s and early 2000s, some colleges of medicine opened at state comprehensive universities such as Central Michigan University in Mt. Pleasant, MI, Western Michigan University in Kalamazoo, MI, the University of Texas Rio Grande Valley in Edinburgh, Texas, the University of Central Florida in Orlando, Florida and other locations (AAMC, 2006, 2012). It appears comprehensive universities have pursued the opportunity to open new medical schools despite the high costs out of a sense of responsibility to meet a public need for more physicians (Mann, 2016). It is likely these decisions were bolstered by the institution's ever increasing undergraduate enrollments, the already successful introduction of a variety of other health professional programs at state comprehensive universities, and the anticipated ability to attract students to new medical colleges to meet the need for additional physicians especially in underserved areas. Apparently, these reasons were compelling enough for comprehensive universities to decide to take the dramatic step to establish a new college of medicine. 17 Decision Making Processes We are reminded by Bess and Dee (2008) of McLaughlin’s (1995) assertion that decisions are the “core transactions” of an organization. While decisions might reflect “core transactions”, Nutt (1999) contends that half of organizational decisions fail, a failure rate that would seem unacceptable to highly engaged governing boards. Decisions fail because solutions are not reached collaboratively but are imposed by the leadership without consideration of alternative solutions through input from employees. Nutt (1999) asserts that managers who set objectives, establish a sense of urgency, consider every alternative solution and involve the right people in decision making are more apt to be successful. This approach suggests listening and seeking input from a variety of sources by governing board members would prove beneficial for effective decision making. While decisions can be controversial or non-controversial, they typically fall into one of three categories – strategic, tactical and operational (Parsons, 1951). Strategic decisions typically focus on organizational structure and implementing its long-term goals. An example would be establishing a new administrative area focused solely on Enrollment Management and the admission and retention of students to address declining enrollments. Tactical decisions then are the methods used to implement strategic plans and operational decisions address logistical questions and those dealing with personnel and technology. Relative to enrollment management an operational decision could mean hiring more staff dedicated to academic advising geared to retaining students (Bess and Dee, 2008). Understanding the decisions made is important. Additionally, it is important to understand whether it is the decision or the process followed that resulted in a decision that is important to know. Bess and Dee (2008) question whether the structure of a decision is more 18 important to understand than the process used to reach it. Chaffee (1983) argued against focusing on the substance of a decision and instead focusing on the process used to reach a conclusion. Chaffee maintained that a decision cannot be made without following a process and understanding the process helps better explain the how and why of the decision. However, the Association of Governing Boards (2014) takes the opposite view and suggests there is too much focus on governing board decision making processes and “not enough on the value and transparency of decisions” (p. 17). Despite the strong views of various researchers on how to study decision making, the process followed by decision makers typically includes a variety of steps according to Bess and Dee (2008). For the most part four processes have been applied to higher education decision making and include methods informed by collegial, political, bureaucratic and anarchic structures (Chaffee, 1983). The initial process is the data gathering phase that helps clarify the problem; then interpreting or analyzing the data which helps to identify possible solutions; determining the most effective solutions; considering alternative solutions; studying the positives and negatives of possible alternative solutions and finally deciding upon a plan and initiating it. Studying governing board decision making requires considering both the process used and the structure of the actual decision made to better understand how and why boards reach some of the conclusions they do. This study focuses on how and why governing board members make decisions at their institutions and the factors that influence their decision making. Governing Board Decision Making Relative to Mission and Resources Governing board decision making is useful and important to understand, and it is expected such decisions help ensure, “that the institution is fulfilling its mission and is positioned to do so for years to come” according to Chaffee (2016, p. 2). Missions are considered important 19 because they help explain what the institution does. Going a step further requires producing a purpose statement to help explain why the institution exists. “Purpose is a promise to deliver something that meets the user’s expectations of value” (Chaffee, 2016, p. 4). As they consider and make decisions, governing boards can be more valuable by paying attention and using their decision-making power to force their institution to better explain why they do exist and asking “why” questions more frequently at board meetings (Chaffee, 2016). Along with respecting institutional missions and purposes when making decisions, boards also need to consider what resources are available when working towards solutions. Resources considered most frequently include finances, personnel, technologies, facilities and property. The Association of Governing Boards (AGB) focuses on finances at universities and explains that the financing of higher education today differs from the fairly recent past. For decades, higher education could count on increasing revenues from increasing federal and state government support coupled with growing enrollments to meet financial needs. Today there is declining financial support from both governmental sectors and in some cases declining enrollments. However, since the recession of 2008 state revenues have finally begun to stabilize for higher education and have increased nearly 2 to 3 percent annually. Unfortunately, that is about half the rate of average increases pre-recession. And much of the increases will be spent to meet the rising costs of employee benefits which grow as much as 6 to 7 percent annually (AGB, 2014). The AGB suggests the challenge for governing boards at universities with declining revenues is to manage costs in order to maintain quality programs and faculty. “This adjustment will force institutions and their boards to pay much more attention to where the money comes from, where it goes, and what it pays for in terms of performance and quality. Doing so will require a shift 20 away from a historic focus on year-to-year fund balances and revenues to measures of costs and benchmarks of performance” (AGB, 2014, p. 10). Decision making for university governing boards has become that much more challenging because of declining revenues and funding shifts. As a result, higher education institutions could be forced to revamp or overhaul their business model and “focus on value and long-term sustainability rather than the traditional focus on consensus-based decision making” (AGB, 2014, p. 7). Higher education institutions will need to clarify their values and better align their resources (personnel, programs, revenues) with their processes (planning, budgeting, program review, educational delivery as defined by degrees and credentials, learning, research, economic development, social mobility, jobs and finally with their investors who are students, the public, philanthropists and employers (AGB, 2014). Decisions are made for different reasons and to achieve different goals in organizations. Nearly 70 years ago Parsons (1951) identified three overarching results of decision making as adaptation, goal attainment and integration and they still seem applicable to decisions of today. Adaptation helps identify how to acquire resources and distribute resources throughout an organization. University governing boards need to consider both the positive and negative impact their decisions will have on institutional resources. It is expected that decisions resulting in resource allocation align with strategic priorities which ultimately circles back to the institution’s mission and purpose. Goldstein (2012) suggested that a university budget represents the campus financial plan from both the strategic and operational perspective. Chabotar (1999) was more direct and indicated that a university budget is the campus plan with dollar signs. Decision making might appear to be a simple matter of negotiating with fellow board members and determining where their interests lie. While that perspective can answer some questions 21 consideration of the university mission and resources are critically important to sound decision making. Theoretical Frameworks As mentioned earlier in this dissertation, I considered a number of theories to help better explain governing board decision making. The first theory considered was institutional theory that suggests the main factor driving organizational decision making is the environment of “political actors, resource providers, alumni, prominent business leaders, and well connected community members (Bastedo, 2009, p. 358). Governing boards that might have been elected or appointed by some of those very groups were supposedly selected to protect their campuses from the influence of those bodies. Institutional theory suggests these governing boards would instead be aligning with those groups to reflect the expectations and values of their organizations. The application of institutional theory could help better explain some recent actions of more engaged boards like the board of Penn State University following the Assistant Football Coach Jerry Sandusky scandal (Strauss, 2012, The Washington Post) and at Hope College in Holland, Michigan which in 2016 attempted to dismiss their president due to external pressure (Jaschik, 2016, Inside Higher Ed). However, institutional theory does not seem the best lens to apply to explain board actions that are very diverse and entail everything from budget setting to accepting enrollment plans. Principal/agent theory could be aligned with institutional theory if it is understood to be the implementation factor of a board operating under institutional theory. The principal/agent relationship is a “construct under which one or more persons (the principals are the governing board) engaging another (the agent or president) to perform service on their behalf which involves delegating some decision-making authority to the agent” (Caers, DuBois, Jegers, 22 DeGierter, Schepers, & Pepermans, 2006, p. 26). Agency theory is often applied in for-profit organizations and has roots in finance and economics but is not as clearly applicable in nonprofit organizations (Caers, et al., 2006; Muth & Donaldson, 1998). In business and industry, the principal/agent theory ultimately focuses on resources and information. At institutions of higher education, the governing board typically identifies themselves as the principal with the president serving as their agent. It is easy to assume that a president views principals and agents in the reverse order. Often the application of agency theory suggests that conflicts arise between principals and agents because they have differing interests and differing views of their roles or one party (typically the agent) possesses more resources, information or data than the principal (Jensen & Meckling, 1976). Since the roles and positions of principals and agents are viewed differently, principal/agent theory often results in more adversarial or contentious relationships between the principal and agent. Other theories considered had an element or two that suggested each could be useful in understanding governing board decision making but did not provide enough context to make it a compelling framework to apply. For example, advocacy coalition theory applies to developing coalitions but solely to impact public policy (Weible, Sabatier, & McQueen, 2009). Stakeholder theory is most appropriately applied to corporate interests and better explains the impact of stakeholder influences on organizational functions and the corporate bottom line (Brenner, 1993). The title social network theory suggests it could provide a lens by which to analyze board decision making because a “social network is the pattern of friendship, advice, communication or support which exists among the members of a social system” (Valente, 1996, p. 70). Typically, the social network theory lens focuses on how an entity such as a governing board can be studied but does not analyze the behaviors, attitudes and beliefs of individual board members. This 23 research study analyzes individual governing board member’s opinions on how a board ultimately made a decision. Thus, it is important to utilize a framework that considers individual thought processes and the factors that affect them leading to a conclusion. From a more negative perspective governing board decision making can result from contentious or adversarial relationships on the board. However, deciding to establish a new college suggests decision making resulting from a more collegial and collaborative perspective. The decision to establish a college of medicine to address a public need while identifying adequate resources to do so has a long-term impact on an institution and requires a long term commitment by the university and board to successfully implement a plan and insure its success. Collaborative decision making suggests that stewardship theory is important to consider. Stewardship theory emphasizes the strategic role of a governing board and recognizes board motives for achievement and recognition, a successful performance, respect for authority, strong stewardship of assets and loyalty to the institution (Muth & Donaldson, 1998) on behalf of the university. Miller and LeBroton-Miller (2006) posit that stewardship theory explains that leaders aspire to a higher purpose whether in a paid position or as a board member. These leaders act with altruism for the benefit of the organization and identify with it and its objectives. These attributes point to a more collaborative relationship among governing board members in concert with university leaders. Drezner and Huehls (2014) argue that stewardship theory is typically utilized to better understand university governance because board members generally entrust presidents to lead and manage their institutions free from major interference. Stewardship theory offers a more positive picture of the working relationship between major actors at a university but it does not ultimately explain how decisions are made. Elements of the three theories of stewardship, socialization and strategic choice theory build a more 24 powerful lens by which to consider governing board decision making. Socialization theory illustrates the importance of social relations in learning and performance which can lead to shared understandings among individuals. According to Nahapiet and Ghoshal (1998, p. 243), “the central proposition of social capital theory is that networks of relationships constitute a valuable resource for the conduct of social affairs providing their members with the collectively owned capital, a ‘credential’ which entitles them to credit, in the various senses of the word”. The networks of mutual acquaintance typically result in respect and friendship that come from being members of a family, a class or a school (Nahapiet & Ghoshal, 1998). Strategic choice theory emphasizes the role of organizations and individuals within organizations actively engaging in developing organizational structures and processes (Bastedo, 2006). In other words, the strategic choice framework is the process through which those with authority and power decide courses of action. However, strategic choice is not only the establishment of structural forms but it also includes the manipulation of the environment and the selection of appropriate performance standards (Child, 1997). Child goes further by referencing Chandler who in the 1960s studied the development of early American business. His definition of strategy provides a likely frame by which to consider governing board decision making. “Strategy can be defined as the determination of the basic long-term goals and objectives of an enterprise, and the adoption of courses of action and the allocation of resources necessary for carrying out these goals” (1962, p. 13). In other words, strategic choice should be recognized as the critical variable in organizational theory. This theory recognizes how a political process operates during which both constraints and opportunities are reflected in the power exercised by the decision makers. 25 By using multiple perspectives or frames one gains a “more comprehensive understanding of organizational life because any one theoretical perspective invariably offers only a partial account of a complex phenomenon” (VandeVen & Poole, l995, p. 511). Utilizing a combination of stewardship, socialization and strategic choice theories (Table 1) builds the strength of a shared understanding, language and narratives among board members who come from different backgrounds and experiences but who enjoy a shared desire to support their higher education institution. It is through this combined lens that I am better equipped to study decisions made by governing boards. 26 Table 1: Three Theoretical Frames Stewardship • • • • • • • • Good stewards of assets Aspire to a higher purpose Altruistic to the organization Identify with its objectives Loyalty to the entity they serve Motives beyond self interest Depth of knowledge Access to current operating information Socialization • • • • Strategic Choice Importance of social relations Relations lead to shared understandings Networks of respect and friendship Networks of relationships translate into a valuable resource for the organization 27 • • • Engaging actively to construct organizational structures and processes Those in authority decide courses of action These actors often have relationships with those outside their organization Chapter Three: Study Methodology This chapter explains the methodological approach to my study. This study analyzed how a comprehensive university governing board considered and then made a decision to establish a college of medicine at their institution. The questions that guided this research were: - What factors influenced board member decision making? - How did board members seek input when considering this proposal? - Who did board members seek input from when considering this proposal? In this chapter I provide details about my study site selection, study participants, data collection, data recording and analysis procedures. Finally, I discuss the study’s trustworthiness and possible limitations. Methodology I proposed to conduct a qualitative study about governing board decision making because it is a phenomenon that is not well understood and an area in which limited research has been conducted (Creswell, 2009). Since there is limited research available about decision making or what influences governing board decisions, there would be marginal value in gathering information quantitatively. Specifically, this study analyzed how a public higher education governing board considered and made decisions about establishing a college of medicine at their institution. I conducted a case study of a public, comprehensive university governing board that considered and ultimately decided to establish a college of medicine. Establishing a professional college is significant because of the impact on existing colleges at the university, the campus, along with the cost and the long-term commitment required of the university in order to attract students and achieve accreditation. According to Glesne (2011) a case study demonstrates a 28 choice of what is to be studied with cases bound, usually in time or place, allowing a researcher to conduct in-depth analysis of a place, phenomenon, or in this case the members of a university governing board. Case studies are valuable because “their strategic value lies in the ability to draw attention to what can be learned from a single case” according to Schram (2006, p. 22). A researcher should focus on the case and its uniqueness and how it links to the social context within which it is embedded. Dyson and Genishi posit that once the question is determined it is important to identify the case, locate yourself as a researcher within the case and then make decisions about how to carry out or design the study (2005). Three types of case studies are outlined by Stake (2004) – intrinsic, instrumental and multiple. A single entity is the focus of intrinsic studies because of the uniqueness of that entity. Typically, the case does not contribute to broader phenomena or theory. In contrast, an instrumental case explores a broader understanding of a certain phenomenon. And finally, multiple case studies explore a specific phenomenon if it will be useful to compare and contrast individual cases. For this study, an instrumental case study method was applied because it allowed for the interpretation of a specific example of board decision making, providing useful and broader insight into that process. Case studies according to Creswell (2009) provide a strategy of inquiry through which a researcher explores in depth a program, event, activity or process – in this study, a board of trustees’ decision to establish a medical college at their institution. Collecting observations, talking with people and reviewing documents allows case study researchers to explore other people’s universes (Dyson & Genishi, 2005). However, researchers need to understand their responsibility goes beyond organizing data. They must identify and analyze the dimensions and dynamics of the phenomenon being studied (Dyson & Genishi, 2005). 29 Site Selection To begin this study, I selected a site, individuals and documents to help me better analyze the problem and the research question. I conducted this study at a mid-western comprehensive university with an annual enrollment of over 25,000 students. It is unusual for comprehensive universities to establish professional programs such as medicine or law because many view that as outside their traditional mission. Hence studying the decision by a board to open a medical college provided insight into how decisions might be made and how board members reached such a conclusion about an unusual case. The university originally opened as a normal school in the late 1800s and over time began to add programs in business, the social sciences, the hard sciences and health care (Cumming, 1993). The majority of students are residents of the state in which the university is located and over three-quarters of the students remain in-state upon graduation either working or attending graduate or professional school. Over 20,000 students attend school on the original campus while others are located at campuses around the state, out of state and online (HEIDI, 2015). A college of medicine was established on the home campus following a vote by the board of trustees during the 2000s. The first class was welcomed five years later and graduated four years following entry into the college. Study Participants Participants for this study included the eight board members who served on the university governing board when the decision was made to establish a college of medicine. These members were appointed by the Governor to serve eight year terms and were eligible for reappointment. Terms of service are staggered so every two years two board members cycle off the board or are considered for reappointment. The Governor has no restrictions, regulations or political constraints on appointments to the boards and does not have to consider any constituencies 30 including the institution’s alumni. Boards have the authority and autonomy to make decisions for their institutions (State Constitution, 1967). However, most appointees are known by the Governor who can attempt to influence board decision making if he or she chooses to do so. At the time of this research, it was unlikely any of the board members who voted to establish a college of medicine still served on that university board because they most likely completed their terms of office. Other participants for this study included any university administrators including the president and provost who served in those positions at the time the decision was reached. Those individuals were most likely responsible for proposing the new college of medicine, or responding to a board proposal to do the same by providing information and responding to questions posed by governing board members. All interview subjects were asked who else should be questioned about this governing board’s decision to establish a college of medicine in a form of snowball sampling to insure that all possible sources had the opportunity to contribute to this study. Data Collection In order to collect data related to the board action to open a college of medicine I conducted face to face, in depth, semi-structured interviews with seven of the eight board members involved in the decision along with appropriate university administrators; after repeated attempts, one member was not able to participate. Kvale asserts that “the qualitative interview is a construction site of knowledge. An interview is literally an inter view, an inter change of views between two persons conversing about a theme of mutual interest” (1996, p.2). This definition helps explain how valuable a person to person interview can be while trying to gather information. 31 I designed the interview protocol and the questions were informed by the three theoretical frameworks of stewardship, socialization and strategic choice. The semi-structured interviews of former board members consisted of the same 13 questions with opportunity to pursue topics that emerged during the individual interviews. Questions were based on some factors identified in the theoretical frameworks to help provide a better understanding of governing board decision making. These confidential, one hour, recorded interviews took place in a private room at board members’ work sites or in their homes depending on their choice. In the analysis participants were identified by a numeric code and pseudonyms were used to protect confidentiality. The guarantee of confidentiality was to insure participants felt comfortable sharing impressions, insights and information relative to the board decision making process about establishing a college of medicine. Interview subjects were asked to do follow up questions in person or during a telephone conversation if necessary. I also conducted a pilot interview with a former governing board member from a different institution to test questions for validity, appropriateness, length and usefulness prior to the research interviews to allow for editing, or the addition or deletion of questions (Glesne, 2011). Additional interviews were conducted with university administrators including the president and provost who served in those positions at the time the decision was reached. Those individuals were assumed to have been responsible for proposing the new college of medicine, or responding to a board proposal to do the same by providing information and responding to questions posed by governing board members. These interviews were also face to face, in depth, semi-structured interviews using modified versions of the same questions asked of board members. These confidential, one-hour, recorded interviews occurred in private rooms on the campus involved, on campuses where individuals now worked, via telephone conversations or in 32 private homes to insure a quiet, non-interrupted area for discussion depending on the interviewee’s preference. Until interviews were conducted I was not going to be aware of any external pressures that possibly played a role in the decision reached by the governing board relative to establishing a college of medicine. During interviews with board members, university administrators or as the result of studying meeting minutes and/or memos if it became clear that external actors (nonuniversity) were involved in advocating for a board decision I would decide then if any interviews with such individuals would be conducted. If so, the same protocol of confidential, face to face, semi-structured interviews would have been followed. However no external actors emerged so none were interviewed for this study on governing board decision making. Creswell (2009) suggests reviewing public documents such as board meeting minutes, newspapers or if possible private documents such as journals or letters in this case relative to the board discussion and relative to decision making. Hence board and university documents such as board meeting minutes, reports provided to the board and news articles were also reviewed to help provide a better understanding of interview responses and university circumstances during the decision-making timeframe. Data Analysis Data analysis requires collecting data from interviews and public documents, then analyzing and coding the information and identifying major themes. Taped interviews were transcribed and coded to identify common themes and perspectives. The analysis and coding were informed by the literature review and the three theoretical frames outlined in the literature review. Coding allowed for the organization of material into segments of text before bringing meaning to the information (Rossman & Rallis, 2012). Four general coding categories include 33 information the researcher expects to find, information surprising to the researcher, codes that are unusual such as retriggering and codes that reflect a theoretical perspective in the research (Creswell, 2009). However, the accuracy of the information needs to be validated before identifying and relating themes and descriptions (Creswell, 2009). It was expected the themes would explain the various methods or techniques used to make decisions, and how and by whom decisions were informed. In this case various themes combined with applicable theoretical frames were identified as part of the governing board decision making processes. Qualitative Study Trustworthiness As mentioned earlier securing trustworthy data is very important in any study. Thus, I utilized participant checking as one technique to improve on the trustworthiness of the study results. I shared the identified themes with some study participants to check their accuracy. I also sought input from the individual with whom I tested questions during my pilot. This individual helped improve the trustworthiness of the study by reviewing the identified themes and suggested a broader lens to use for expanded interpretation (Glesne, 2011). Role of Researcher Prior to conducting a case study a researcher must realize their “data gathering, analysis, and indeed, eventual write-up of others’ experiences are mediated by their own lives” (Dyson & Genishi, 2005, p. 81). In other words, every researcher has a personal biography which includes their race, class, gender and ability. “Who we are outside our identities as university researchers influences the kinds of questions we ask and the kinds of collaborators and participants we select for our studies. Who we each are also figures into how we collect, analyze and interpret data”, which is especially true in qualitative research where the researcher is the instrument for data gathering (Dyson & Genishi, 2005, p. 57-58). 34 Before conducting in depth, semi-structured interviews of the eight board members who served on the board when the decision was made to establish a college of medicine I needed to identify that I am a professional who works at a public, comprehensive university that established a college of medicine. Additionally, while serving as a vice president for government and external relations I served as a Special Assistant to the President for the College of Medicine. As a member of the President’s Cabinet and executive team I have interacted regularly with a university governing board while they considered and made decisions about issues as varied as university budgets, admission standards, tuition rates, capital master plans and other challenging issues. Personally, I have served as a university governing board member and recall the various formal and informal decision-making processes utilized by myself and others when asked to make decisions about similar issues and policies. Thus, I have the advantage and the challenge of possessing some insight and experience with governing board decision making that could influence my reaction to the information I gathered during this study. Limitations I have explained concerns about my own limitations (or benefits) as a researcher. But I also had concerns about potential limitations from study participants who would not be as forthcoming as necessary about a governing board decision to establish a college of medicine. Since the decision was made nearly eight years ago these individuals simply might not recall their motivations or how or why they decided to support the opening of a new college of medicine at their institution. Responding to the interview questions required a certain level of self-reflection that could be a challenge for participants. In 1990 Haring-Hidore, et al. explained that their study participants “had considerable difficulty in reflecting on their ways of knowing” and decision making because they are complicated processes that take time to develop and may 35 almost become second nature to individuals so are more challenging to discern and articulate (p. 179). Despite these possible limitations, one-on-one interviews still seemed the most effective method to collect data. In fact, as the interviews took place, participants seemed confident in recalling the most important information for this study. Some details were challenging for board members and administrators to remember but I took those omissions into account in my analysis. I was confident in the value of what they shared. 36 Chapter Four: Board of Trustee Findings An effective way to study governing board decision making is to listen to the decision makers and those who can impact those decisions. Analyzing the governing board member and university administrator interviews from this study led to a variety of findings about how a governing board decided to establish a college of medicine. The earlier methods section of this dissertation detailed who was interviewed, how confidentiality was provided to participants and how interviews were organized and conducted. These findings focus on governing board member recollections of their decision-making process that resulted in the establishment of a college of medicine at their institution. The findings resulted in identifying five major themes on governing board service, why a college of medicine was proposed, gathering and analyzing information about the proposal, who initiated and led the new college initiative and why the college almost was not established. Governing Board Service The university board members who participated in this study came to serve on the board from different paths but all were appointed by the Governor. Some were alumni of the institution, some sought the appointment, some had served on other boards and the appointing authority (the Governor) was aware and impressed with their work on those boards, and some even worked for the Governor. Examples of participants’ recollections of how they came to serve on this board included: “I was on the Governor’s staff and told him I was interested in serving on a university board. Higher education is what really can transform an economy, communities and it transforms young people’s lives.” (4th board member) “I was an alum and professionally I had worked with a number of higher education institutions so I had some background. I also had served on the board of a private college so I had an idea of what I was getting into when I was asked to serve. I was happy to reconnect with my alma mater by being on the board.” (1st board member) 37 “Both my husband and I hold undergrad and graduate degrees from here and we also lived in the community. I knew the Governor and he knew my background and I think that is why he asked me to serve on the board.” (6th board member) The university also advocated for certain individuals to be appointed who could provide expertise in areas that could benefit the university. Seven members of the eight member board participated in this study. Four of the seven members were alumni of the institution and three were not. Some board leaders did not think it mattered if members were alumni or not because they worked together on behalf of the university. “You see a little bit more congeniality, I think in appointed boards, a little bit more teamwork. We’re all on this thing together. Let’s try to work it out and give a single face and position for what we are going to decide and the direction we’re going to take. And our support of the president which is an important part of that.” (1st board member) Participants admitted they found serving on the board challenging but felt they brought value to the board and the university. Their varied professional experiences impacted their board service and ensured they brought differing perspectives to the board table, as illustrated in this participant’s comment: “I was completely different than other people on the board. I don’t believe there was anyone who had a professional background like mine on the board. I think I brought a very different perspective to the board table.” (1st board member) One board member served in various leadership roles in state government for over a decade followed by a career in private consulting. Another was a senior executive vice-president at a major health care organization. Other members with unique professional experiences included a senior executive vice-president of an international communications company, the owner of a nationally recognized communications firm, a money manager, a chief operating officer of a housing corporation and a physician. In addition to their careers, their professional roles often led these individuals to serve on a variety of profit and not-for-profit boards. As a 38 result of their professional lives and prior board experiences, participants had differing views of how boards should and did operate as the following comments suggest: “People on the board are very successful but when you are brand new and don’t know much about how a board is run or how a university is run, I was a little intimidated. But I knew I could bring something to the board from the business end, not academics.” (3rd board member) “I really thought we would just deal with academic issues. But we dealt with operations, facilities, athletics, the local community and a variety of issues that kept the college functioning.” (7th board member) “Because of my professional experience I had a broad understanding of state government, the economy, the private, public and non-profit sectors. So, I had a broad view of what role higher education can play in the state.” (4th board member) University board members’ responsibilities include making decisions and voting on issues as varied as annual budgets, bricks and mortar projects, tuition, student admission profiles, labor contracts, campus master plans and much more. In addition to these more typical decisions, this board was eventually asked to consider establishing a new professional college at their university – a college of medicine. The Idea: A College of Medicine Board appointments at this university are for eight years with staggered terms. It is important to realize that when the proposal to establish a new college of medicine was suggested, every member had served on the board for a different period of time. Staggered terms meant that every two years, two board members cycled off the board and two new members were appointed. As a result, each board member had their own unique recollection of when and how they first learned of the proposal to establish a college of medicine. Some board members who began their board service in the early 2000s recalled there was general discussion about opening graduate or professional schools from the time their board service began. For example, the possibility of opening a law school or an engineering program was discussed at different times. At about the 39 same time there was also growing recognition of the growth and strength of the varied health professional programs at the university. In fact, a new state of the art health sciences building opened in 2004. It was expected this facility would enhance learning opportunities for health professional students, faculty and researchers. In the mid-2000s a physician was appointed to the board. This board member spent time early on analyzing the university’s strengths and recognized the institution had strong doctoral and master’s programs in the health professions such as audiology, neuroscience, physical therapy, hospital administration, physician assistant and basic sciences. “When I was appointed I was given the university’s five-year plan to review and I did not think there was anything earthshaking in it. I kept looking at how to leverage the academic aspects of the institution with the clinical aspects of the area hospitals. I was also thinking that could help grow the university’s economy. Growth in life sciences was the best avenue for academic development and economic development of the university. That’s why and how I began to envision a medical school in our geographic area.” (5th board member) This board member’s analysis led him to propose establishing a college of medicine. The majority of board members recalled first hearing the medical school proposal from their fellow board member, as this participant recalled: “When we spoke the physician board member suggested there’s a need, no physicians want to work in rural areas. They all want to go to bigger cities and work with large healthcare systems. They all want to work with practices that have a lot of doctors. Maybe we should look at all this at the same time. This made a lot of sense to me.” (1st board member) However, during early discussions about the possibility of establishing a college of medicine the enthusiasm of the physician board member who originally proposed the college was interpreted by some other board members as self-serving. There was concern about whether he, as a practicing physician, would benefit from the opening of a new college of medicine. Also, the proposal was presented in what one board member thought was a clumsy manner: 40 “The proposal was brought up cold. I think it would have been easier had he, at least for me, had he sold me on the idea one on one. I was never against it but I would have come around quicker. That’s how I would have presented it. I would have said, “Look, I really think there needs to be a med school. We’ve got a shortage of doctors in rural Michigan. I think that we could fill a void and let me tell you what that process is.” Initially I thought he was being self-serving. In the end, I think he recognized a need and that our university could fill that need. So, I give him credit. He saw a need and he had a vision that I did not have.” (6th board member) Other participants appointed to the board after 2005 and prior to 2010 indicated they heard about the possibility of a medical school from the university president. “I think the first thing I was thinking is why would you do this? I mean why would this university want to have a medical school? So, the first thing I heard is that there was huge demand. So, if you could open up something that has huge demand, and you can almost command any price, maybe this is a money maker.” (3rd board member) “We weren’t trying to compete with other universities in our state. We were going to try to service the rural areas around us and north of us. Because the physician shortage will be extreme and it’s going to hit the rural areas really hard. Once all that was on the table, it dawned on me that the purpose of this medical school wasn’t as a big financial status symbol at our university, it was really to do some good.” (3rd board member) Filling the Information Vacuum More discussion about the idea of a medical school was beginning to occur but the board and university leadership recognized they did not have background or experience in how to establish a professional school such as a college of medicine. With this realization, the board began to gather internal and external information in a variety of ways as this board member observed: “When I was in a board leadership role I finally said why don’t we start figuring out if we are going to propose a med school or not because I think this makes all the sense in the world.” (1st board member) This section explores many of the different ways the board sought information. A few board members indicated they were intrigued by the idea of opening a college that would produce doctors to serve rural areas in the state but were very aware of how little they knew 41 about establishing a college of medicine. For these board members filling the information vacuum became a high priority, as these comments suggest. “I am on board with the new college idea. But I’ve never had anything to do with a medical school. How do you do this? It would not be good for the university not to do this right. But I didn’t see anyone around the table who’s ever been on a committee that opened a medical school.” (3rd board member) “I did not know how to start a med school. It was all very foreign to me. I almost felt like I did not know what questions to ask. It was also a new idea to the president’s direct reports. So there was a credibility issue for me. I felt like we were more reliant on our physician board member and the president, one of whom I did not trust.” (6th board member) “I remember at the very front end there was a lot about the need for the school but then we wondered who would partner with us on this project and could we raise enough money to be sustainable and could we be accredited.” (7th board member) Thus, a variety of information gathering efforts were initiated relevant to opening a college of medicine. One of the first of these efforts was to meet with officials from another university that recently established a medical school. The initial, and what turned out to be the only visit was to a new medical school in a distant state. The president and two board members traveled there and met with the university’s president, the dean of the college of medicine, chair of the university board of trustees and the provost. One member who went on the visit recalled, “They could not have been more helpful. They were spectacular with the insight they gave us. They didn’t pull any punches. They told us what to watch out for, what to be careful about, what to do, what not to do, mistakes that I think we probably made.” (1st board member) That university team outlined possible reactions to expect from faculty and non-medical faculty who typically would not be supportive of establishing a college of medicine until and if they recognized what the total impact could be for their university. Upon returning to their home state the threesome claimed they reported to the rest of the board what they had learned and indicated they felt their university could successfully launch a college of medicine. One of the 42 team of three recalled, “This is very doable but it has to be done methodically and carefully and in phases and we cannot let our eyes get bigger than our stomachs,” (1st board member). While the three university representatives greatly benefited from the visit with the other university’s leaders, their fellow university board members did not recall hearing much about the visit or the outcomes. Even while some board members did not remember the visit, the leadership team did present their findings to some of the area hospital representatives who liked what they heard. In fact, the hospital leaders were so interested in seeing a new medical school established they suggested immediately establishing a medical school board composed of area hospital and university representatives. The university declined because as a public university it did not believe it could organize with representatives outside the university and did not want to participate in a free-standing college of medicine entity independent of the university. Feasibility Study In an attempt to gather additional information about opening a medical school, the university launched a feasibility study. Members of the board and president who visited the recently opened medical school out of state learned of an advisor who provided counsel to that new medical school. This advisor also served as a vice president for a key division of a medical school association. So, the university hired the same advisor to analyze and then report to the board on whether this university could or should also proceed with establishing a college of medicine. Recounting the reactions, one board member indicated, “The question we kept asking was is there viability in what we are proposing and what was proposed to us” (7th board member). This initial feasibility report was an important source of information for the Board of Trustees as they worked towards making a decision about whether to establish a college of 43 medicine or not. The author of the feasibility report completed in late 2007 identified two tenets the university would have to accept if they wanted to move forward and establish a medical school. 1) If the university was going to consider opening a new and expensive program such as a medical school they would need to do so without reallocating any university funds already committed to existing colleges. 2) Additionally, the university could not expect any state funding to be appropriated to establish a new college. Along with accepting those two tenets, the report’s author insisted that university leadership would need to understand the complex nature of the challenge to launch a new professional college of medicine and be committed to establishing a high quality educational program if they expected to move forward. In the feasibility report much attention focused on the resources necessary to support a medical education program due to the “standards” set forth by the Liaison Committee for Medical Education (LCME) for accreditation purposes. Relevant standards exist in five major categories: the institutional setting, the educational program, medical students, faculty and educational resources. The detailed standards are outlined in the “data base” that schools must submit to the LCME in anticipation of an accreditation site visit. Standards vary depending on the stage of the school’s development. (feasibility report) Specifically, the author of the report charged the university leadership to respond to three major requirements from the LCME. 1) The university would need to provide a facility that could meet the college’s instructional and administrative space needs. 44 2) The university would have to prove their ability to acquire enough funds from various sources to finance the early phase of the college’s development. (Historically, other developing medical schools in the U.S. incurred annual costs ranging from $5 million to more than $l5 million.) 3) Finally, the university would need to establish academic affiliation agreements with various clinical partners including hospitals, nursing homes, hospices, clinics and other health care organizations. These agreements would provide medical school students access to patient care settings to obtain clinical education experiences required in the educational program. According to the author of the report, forming relationships with potential clinical partners had turned out to be the most complex issue faced by developing schools across the country, largely because of an incomplete understanding of the variable nature of affiliation agreements by the school’s parent universities. (feasibility report) The report further indicated that while this university was considering establishing a college of medicine, a number of existing medical school expansion efforts were already occurring within the state to address the need for more physicians. More than once the advisor suggested that instead of opening their own college of medicine, it might be more prudent for the university to partner with an existing medical school as a way to establish a medical education program. Two board members reacted to the advisor and the report recommendations this way, “We did bring in a sort of accreditation person who didn’t turn out to be all that great but he helped us frame the discussion of what it meant to establish a medical school. I do think he misled us on a couple things.” (4th board member) “The report’s author was too simplistic in his report. He suggested a medical school could be established without spending millions of dollars and that did not happen. But the report did have value. It definitely encouraged moving forward. The report said the university had many strengths in basic sciences, health professions, and information 45 technology so the university is more than suitable to develop a medical school.” (5th board member) The report spelled out the requirements for accreditation that one board member saw as the steps the university would need to follow to achieve accreditation. “We needed to know if we could comply with these requirements because if we couldn’t, forget opening a medical school. People at the university told us we could do this but it was going to be hard and there would be bumps along the way. I think we all thought we could get accredited before we voted on the proposed college.” (3rd board member) The governing board and university administrators were not satisfied with this one feasibility study so began seeking additional information from sources internal and external to the university. That information is unpacked throughout the following sub-sections. The Medical School Vision Committee In January, 2008 the president established and charged a Medical School Vision Committee of 11 administrators and faculty members from programs across campus to develop a vision for a medical school at their institution. The committee was comprised of research, technology, and graduate studies administrators as well as a representative from the Academic Senate and faculty members from chemistry, biology, philosophy and health sciences. A college dean chaired the Medical School Vision Committee. The specific charge to the committee was two-fold: 1) To collectively explain what the expected impact of a new medical school would be at the university, in the community and region 20 years after the school was established. Said another way, the charge was to develop a 20-year vision for a medical school. 2) To collectively indicate the type of medical education program that should be established to meet that 20-year vision. 46 The vision committee completed their work in February, 2008. Their conclusions focused on insuring medical students would graduate with excellent clinical, diagnostic, and personal care skills with a commitment to life-long learning and the highest ethical standards. The report did not refer to a physician shortage but does mention many times expecting the need to have a large proportion of graduates who would practice medicine in underserved rural areas. Additionally, the report indicated a medical school would help increase the number of physicians practicing in northern and central locations of the state. The committee suggested a profile of potential medical school students as those with strong grade-point averages and MCAT scores who had studied traditional sciences; a history of volunteer activities with evidence of experiences in health care delivery. The vision committee also proposed a problem-based learning curriculum to enhance students’ critical thinking skills and improve their ability to work in teams. Finally, they recommended opportunities to learn to use technology effectively in the diagnosis and care of patients especially in rural areas of the state with limited access to other health care professionals. In the vision committee’s opinion, a medical school would attract more highly qualified students to the institution and result in the hiring of more productive and innovative faculty in the biological sciences and medicine. A conclusion of the vision committee was that those changes achieved by establishing a medical school would enhance the external perception of the institution. Ad-Hoc Medical School Committee During this time when the governing board and the university gathered information, it was determined a board committee focused solely on the possible establishment of a medical school would be useful to the governing board. Through this committee the board was kept 47 apprised of discussions with potential hospital partners, discussions university administrators were having with the LCME (the medical school accreditation organization), the organization of the medical school, potential funding efforts, possible facilities and other issues relevant to opening a college of medicine. The ad-hoc committee typically received reports and updates from university administrators and some external advisors. It continued to operate as a freestanding committee until April, 2013 when the governing board folded it into the board’s standing committee on Academic Affairs. Additional External Report As senior administrators and board members began to amass information from individual sources and the LCME relative to establishing a college of medicine, some doubts and skepticism were cast on the original feasibility study. In order to address those concerns, another external report was commissioned by the university from a nationally recognized consulting firm. Presented to the board in November, 2008, their report reacted to claims in the feasibility study about the level and sources of revenue necessary to establish a college of medicine. Specifically, this report focused on areas such as funding models for a new medical college, the structure of a medical education, possible class size, financial aid, where the college should be located, required facilities and a possible start date for the first class in a new college of medicine. Comments from both board members and university administrators indicated they had more confidence in the data in the second feasibility report so deliberations continued to move forward. 48 Other External Sources Along with gathering information from external advisors and campus administrators and faculty, individual board members also consulted with their own external sources to solicit input about establishing a college of medicine. Two participants remembered seeking external input this way: “I certainly spoke to others and the question was always why are you considering this when we already have medical schools. I responded that the existing medical schools weren’t producing doctors who would stay in Michigan or were interested in serving a population that needed it the most.” (4th board member) “At the time, I was working in healthcare and I would have water cooler discussions with people about the med school idea. People in my world did not think there was a need for another medical school. I did bring those comments back to the board but the comments were a broad stroke. Then again there were others at my work place who thought it was a good idea.” (7th board member) One board member discussed the possible medical school with their own doctor. After explaining that the college’s mission would be to educate primary care physicians and help address the physician shortage in rural areas of the state, the doctor thought it was a “fabulous idea”. The doctor then remarked that if the university stuck to that mission it would be providing something needed. In another example of seeking external input a board member sought counsel from a former trustee who served on the board prior to any discussion about possibly opening a college of medicine. This individual had a long career in finance and shared that expertise with the university while serving on the board. According to the board member who participated in this study, “This former trustee knew the inner workings of the university and he gave the board a lot of good advice. He told me he had run the numbers and concluded this college of medicine would never be profitable. He said between the debt service and the cost of physician faculty members and not enough tuition money to cover the huge costs it just can never be profitable.” (2nd board member) 49 It is the rare college of medicine that makes an annual profit, and both board members and administrators indicated the new college of medicine idea was not proposed as a unit that would result in additional revenue for the university. Instead, the goal of establishing the college of medicine, as stated, was to meet a need to educate more physicians to practice medicine in underserved areas that were experiencing physician shortages more acutely than other regions of the state. Considering the Data Information from external and internal reports and input from other sources had to be unpacked and considered by board members as they worked towards making a decision about establishing a college of medicine. Information seemed plentiful for the board to digest. But how did the board process the information? Did they do so as a board entity-or independently? Was there board interaction while they considered the idea of a college of medicine? In the minds of some the interaction among board members really depended on how long one had served on the board. One of the longest serving board members during this time period shared how the board seemed to process information at that time. “This often happens on boards but when you have newer board members who aren’t as engaged or maybe aren’t as informed, and to their credit realize they are not, they listen more and maybe do not voice an opinion as quickly. I sort of was that way when I first joined the board. But then you had others on the board who were quick to question, to poke holes. I am not saying that is wrong because that is part of the job so long as we are not micromanaging. But certainly, to ask good questions, I think is healthy and that’s really what we ought to be doing. So, there was that interplay on the board at that time.” (1st board member) In general board members agreed there was interaction and discussion about board matters even if individuals were not spending time together away from the university. Conversations often took place during the two days board members were on campus for board meetings as noted by these three participants: 50 “I was too busy with my job to take a lot of time away from it to talk but when I was at the university I would catch up. At some point, you have to trust that some board members know more than you do about a topic.” (6th board member) “I felt everyone was engaged on this topic because before every meeting I would call board members to see if they had any questions about the college of medicine that they wanted to discuss. I also sent group emails to all the board members as well to keep them abreast about what I knew, what was happening and what the progress was.” (5th board member) “As the idea of a college of medicine advanced one of the things that happened on the board is that members would bring their expertise to the conversation. When they brought their perspectives based on their specialty areas that broadened our discussions and made them richer with so many different competencies at the table.” (7th board member) “One board member who was generally supportive of the proposed college had an insightful reaction to how the board interacted during this time. There were a lot of men on the board who were not particularly interested in what a younger woman had to say or think. So, I always felt like I had to really push to get answers and to get info. And I was not an alum of the university and there were some alums on the board who knew each other, had a long relationship, and had similar backgrounds. They were all the same gender so they felt more comfortable with each other than with others of us.” (4th board member) Some board members’ experiences are important reminders that boards are just that and not groups of friends or colleagues who happen to get together to determine the future of an university. Processing the information that was collected about establishing a college of medicine was difficult enough but there were also challenges because eight unique individuals had to learn how to work together to make decisions. Decision Leader For the majority of study participants memories of board interactions during this time were not particularly strong, but most board members agreed two individuals had the most impact and did the most to convince the board that the university should establish a college of medicine. Almost unanimously board members identified the president and/or the physician 51 board member as having the most influence on the board during their deliberations about establishing a college of medicine. This participant’s comment reflects what many remembered: “It was not like one person was calling the shots but I vividly remember the president and the doctor being the two people who devoted the most time, and the most effort convincing everyone that we should do it and why we should do it.” (2nd board member) Most board members expressed trust and confidence in the president as he championed the new college proposal. The president was viewed as having good insight and was a fair player and purveyor of facts and data. But it was a combination of efforts from the president and the physician board member along with the detailed information provided to the board from staff helping lead the project that ultimately convinced the board of the value of the proposal. At the same time, some on the board were also aware that the president and the physician board member’s interest in establishing a college of medicine could be misinterpreted as noted in these comments: “The president was the champion of the idea but he was smart enough to bring in other people. He almost has a conflict, right, so he made sure we had the information and the people telling us what we needed to do to get there and have us vote yes.” (3rd board member) “There were board members who trusted the president more than I did. But when we heard from the individual who came from the accrediting body he impacted me. This guy said we can do this. This guy says it’s not out of the realm of possibility. He was an outside source who I didn’t believe had any personal gain to make so he was more objective.” (6th board member) “Throughout the process my questions were answered and my observations were respected by the administration. But in the end, you have to trust the executives you are working with for their unfettered and truthful depiction of this issue (the proposed medical school) or any issue.” (4th board member) While there was some distrust of the president, the physician board member and external advisors in this decision-making process, the board was still successful in reaching decisions 52 they all could agree with. The next section details the decisions ultimately made by the board members. The Medical School Decisions The original feasibility study and analysis combined with additional information, other studies, data, board perspectives, and internal and external opinions about establishing a college of medicine led the board to cast an important vote. On December 6, 2007 the Board of Trustees unanimously passed a resolution that allowed the university to continue gathering information about establishing a college of medicine. Specifically, the resolution stated, That the university continue with planning, processing and exploring the feasibility of a medical school at the university. (Board meeting minutes) For some board members, this action was the culmination of years dedicated to studying and vetting the idea of establishing a college of medicine. Other board members had only served on the board for six months when this first vote was taken so they had only attended three formal board meetings at the time. Despite the fact that individual board members had varying levels of information, and in some cases limited board interaction with the proposal and with each other, the support for moving forward to establish a new college was unanimous. This first supportive vote by the governing board in 2007 resulted in continued information gathering and drafting plans to establish a college of medicine. The proposed plans drafted by the administration then went before the Board of Trustees for further consideration. Those additional efforts culminated in another unanimous Board of Trustee vote in September, 2008. This resolution was presented to the Board of Trustees at the request of the board’s AdHoc Medical School Committee. Specifically, the resolution stated, That the president is authorized to proceed with planning to establish a medical education program/medical school at their university. That the president or designee is authorized to inform the Liaison Committee on Medical Education (LCME) that the university intends 53 to move forward toward obtaining accreditation and to initiate that process. (Board meeting minutes) The board resolutions provide proof that the board of trustees did indeed support the idea of establishing a college of medicine after much study and consideration. While the board actions taken are critically important, it is interesting to study why board members voted the way they did. As one board member said, “this was not a decision anyone on the board took lightly.” The next two sections include the reasoning of some board members. A College of Medicine: Why? Governing board members indicated they ultimately supported the establishment of a college of medicine at their university in order to address the physician shortage in the state. In fact one board member’s motivation came from a passionate desire to meet needs in the state and address physician shortages especially in the underserved areas of the state, recalling as follows: “I have some background working in Medicaid and had just worked in a state department working on issues with low income individuals. Healthcare is just one of the fundamental issues about why we do not have people working in this state, why we don’t have healthy children, why we have infant mortality issues, low vaccine rates, etc. So, you can sort of list off a whole host of health issues within the state that exist with the 10 million people who live here. And if you don’t have access to health care, those issues just don’t get resolved. People then can’t get an education. They can’t go to work. They can’t take care of themselves, their families, etc. So that healthcare piece has always been something that I felt very strongly about as a fundamental issue that needs to be addressed.” (4th board member) Additional members spoke about their desire to try to meet the growing need for physicians as a compelling enough reason to establish a college of medicine. “I think we felt that the university would be doing a great thing for the state by helping those in more rural areas to have their medical needs met. We saw a path to meet that mission that was set out from the very beginning. And if it hadn’t been apparent I don’t think any of us would have voted yes. So, I think we all felt that we had gotten to the point where we were going to be able to successfully meet the mission of servicing the rural areas with good doctors.” (3rd board member) 54 “And I think there came a point, and I don’t want to overplay this, but that maybe we felt like people were counting on us to do this. That we had an opportunity to really make a difference in the state, in people’s lives, and in the rural areas. And to offer an opportunity for high school students in our state to remain here, and attend a medical school that was a good option from the others already in the state.” (1st board member) As might be expected based on opinions expressed earlier in this dissertation, one board member had strong opinions about opening a college of medicine because in his opinion, the board had not given enough consideration to the actual cost of establishing a college of medicine. This participant speculated that board members may have been more motivated to support the proposed college of medicine because they thought it would improve the prestige of their institution. The inference was if the university was growing and expanding, it helps make a name for the institution as noted in his comment below: “I don’t think anybody on the board thought a college of medicine was ever going to be a money maker. I mean it didn’t take a genius to figure that out. I think the institution wanted to be thought about like other universities in the state that already had medical schools. That may have had something to do with this proposal.” (2nd board member) Meeting a need, and/or increasing prestige are not mutually exclusive concepts and can be embraced simultaneously, as another board member suggested when saying: “I think having a medical school made the university more competitive, but the school could also serve a broader community need and be sustainable.” (7th board member). So, the majority of board members did express a desire to address a need in the state for more physicians as the reason they supported the proposal to establish a new college of medicine. The Decision-Making Process Governing boards are expected to make a variety of decisions. And despite the magnitude of this specific decision, the majority of board members agreed that the decision-making process they followed to establish a college of medicine was for the most part similar to other decision- 55 making processes they had engaged in. The following comments reflect board members’ overall sense of their decision processes: “I think it was pretty similar. We asked staff to develop financial models, answer the what ifs, and that kind of thing. Much like we would do if we were building new buildings or looking at something else new at the university, curriculum wise or whatever. So, I think it was very similar.” (1st board member) “I think the decision-making process was really similar to other decisions since we approached it as one of the colleges in the university. We considered the global impact on the university, the potential for the medical school to increase the biosciences undergraduate enrollment.” (5th board member) “The decision-making process seemed similar but this was one decision that would have been just as easy to have said, let’s not proceed because of the stress on us. We knew we could not make a mistake. You wonder if the timing is right. But is there ever good timing for something this big and long term?” (3rd board member) Some board members recognized that the information necessary to consider such a proposal was more in depth than for other board decisions but the process was similar, as reflected in the following: “I don’t know if we ever received as much information as we received for the college of medicine. We had this feeling that we better be very, very, very careful, which you should be about any decision, but we might have gone overboard gathering info that we didn’t even need to make a decision. But I don’t recall other decisions being this intense. There was this sense that we have to do this right. Other things we knew we could get right without as much information, but this was different.” (3rd board member) “It was a similar process to other decision-making processes. We had a lot of discussion, a lot of data and information. And I think we were deliberative. It wasn’t like we would talk about it on June 1st and then on June 30th vote for it. It was a longer and more deliberative process.” (7th board member) Two board members indicated they felt the decision-making process differed from other decisions for a couple reasons, captured in these reflections: “There was more info needed to consider from external sources so that made it different. It also took a longer period of time to decide. And it was brand new, it was like virgin territory. It really was a process and it could not have been done any other way. Whereas with tuition increases, you decide them every year.” (6th board member) 56 “I do think this decision-making process was different. We were creating something that had never been developed before. So, there was not a roadmap or anything. It was new and innovative. We were trying to pioneer, innovate a new college. So, there was a different level of interest and participation. We were starting from scratch, so it was a little bit more intense and not as prescribed as some of the other things that we made decisions about. So, we were learning as we were doing it.” (4th board member) The opinions on the similarities and differences in the decision-making process are just that – opinions. Neither position is right or wrong but these reactions indicate that processes were viewed through individual lenses by various board members. The Decision in Retrospect The governing board decision to establish a college of medicine was approximately ten years prior to this research so board members had time to contemplate the decisions they made about supporting a new college. All were comfortable they had made the right decision and were pleased with the progress being made by the university towards establishing the college, securing accreditation, hiring faculty, welcoming the first class of 62 students and seeing them graduate. However, most agreed it could and should have been a better-informed decision, as indicated by this board member’s response: “First of all, if I hadn’t been so busy at my job, I would have spent more time researching the proposal. And I felt bad I could not do that but I just couldn’t. If I had it to do over again I would have suggested more time be spent on consideration so I would have had more time to ask questions and to go to different sources to ask those questions. And I would have wanted to consider the proposal with a different president that I trusted.” (6th board member) This board member felt that more education of the board would have been helpful and was a critical component missing throughout their deliberations, saying, “I would have done much more stakeholding with the board. I would have done more education with the board. I know I voted yes but I felt so vulnerable, so out there. I didn’t feel secure with the decision.” (6th board member) 57 As the conversation with this board member continued, it was obvious that some of the impressions were the result of how the university president interacted with the board. In this individual’s view the president mistakenly focused most of his attention on the board chair and vice chair when deliberations were ongoing about the possible establishment of a college of medicine. “When you have a board with only eight people everyone is equal and should not be treated differently. Boards that are small often make the mistake of treating the chair and vice chair differently than the six and this president did that. That causes problems within the board.” (6th board member) Another board member who was part of the delegation that visited the new college of medicine out of state acknowledged that visiting the new medical school was beneficial. This participant indicated it would have been useful to visit at least two other universities that had recently opened, or were soon to open a college of medicine because they could have gathered more information to compare, contrast and consider as part of their own deliberations. Additionally, this board member admitted that other board members should have also been invited on these school visits. A second board member volunteered that learning first-hand about other university’s experiences while establishing a college of medicine would have been beneficial. Two participants, one who had not served on the board during early discussions about the college of medicine proposal and one who had, suggested, “Maybe we should have taken a bit more time and increased the transparency and talked about the proposal more publicly and shared with people what we had learned, identifying more options and getting more buy-in.” (3rd board member) “It was amazing we actually got the college of medicine approved as swiftly as we did. It all moved pretty quickly. Today, I guarantee it would not have moved so quickly. There would have to be a lot more opportunities for people to offer input, ask questions. We would have probably had to have panel discussions on why we need to do this.” (1st board member) 58 These were intriguing comments because some board members clearly recalled many presentations about a possible medical school being made to the academic senate, the academic council and the graduate school and student committees. Throughout the interviews with participants most acknowledged there were potential pitfalls to opening a new college of medicine that should have been examined earlier in the decision-making process. As one board member shared, speaking for several others, “I should have been more interested in the leadership of the college sooner rather than later. You know, once we got this college up and going who is going to take the baton and make this work.” (7th board member) Another board member admitted that when the board voted to establish the new college it was not known if the hospitals needed to partner with the college of medicine had been identified or would sign affiliation agreements. “Specifically, the biggest issue moving forward was getting affiliation agreements so you would have places for these students to continue their studies. Those were also required as part of the accreditation process.” (3rd board member) Throughout one interview, a board member consistently expressed concern about the cost and financial implications for the university of opening a new professional college. Before voting to support the proposed college, this board member wished the board had required the university to raise more money to settle some of the institution’s overall debt prior to taking on more debt with the opening of a college of medicine. He reflected, “At some point the board and the university are going to have to pay the piper and it’s going to be painful,” (2nd board member). Another board member saw the cost and funding of the new college differently and from a more positive vantage point. He stated, “We did ask what establishing a college of medicine would cost. What funding would need to come from the university general fund and other funding streams. It seemed the college would be self-sufficient once it began to accept students and they paid tuition. So, we thought the financial impact on the university would be minimal.” (4th board member) 59 The College of Medicine That Almost Wasn’t Even after all the years of study, consideration and votes taken by the board of trustees, the college of medicine was almost not established. The board unanimously took their most important vote at their September, 2008 meeting to establish the college. Five months later, in February, 2009 the president announced his resignation effective in June of that year. The potential impact that decision almost had on the governing board members was significant, as these participants shared: “I was chair at the time when he announced he was leaving and I was angry. I don’t think anyone was as pissed off as I was. I felt like we were taking this huge risk and he left us holding the bag.” (6th board member) “When we voted for the college everyone was of the belief that the president was going to be here and see this through. Once he accepted the medical school challenge and responsibility he should have seen it through to completion.” (2nd board member) “When the president announced his resignation some of the trustees wanted to pull out of the medical school. They asked me if without the president we should cancel the medical school. I stayed cool and said we could consider that if necessary but let’s wait and see what the hospitals say. So, I kept it brewing.” (5th board member) An interim president was appointed immediately following the president’s resignation announcement. The interim president was assigned to work directly with the outgoing president in order to keep a number of projects at the university moving forward including the college of medicine. As a result, all systems were go and the governing board worked closely with and supported the interim president’s efforts to establish the new college of medicine. It is apparent this governing board made up of individuals with varied backgrounds and relationships with the university spent considerable time studying, considering and analyzing information and motivations before making the decision to establish a college of medicine at their institution. Once presented with the medical school proposal the board seemed determined 60 to conduct their due diligence and make a decision they could all support that would benefit their university and their state. One board member summed up their efforts this way. “I thought we needed to make sound judgments based on facts, a sound business case and we needed to make decisions in the best interests of the institution’s students.” (4th board member) Ultimately, the board did vote unanimously to establish a college of medicine. In the next section of this dissertation, the recollections of senior administrators who were the most responsible for providing information to the governing board as they deliberated towards a decision about whether or not to establish a college of medicine are explored. 61 Chapter Five: Administrator Findings It is apparent why Board of Trustee members who made the decision to establish a college of medicine at their university were interviewed for this study. However, another important group of individuals interviewed were senior university administrators who served at the time the medical school idea was proposed and then became a university initiative. These administrators included the president, provost, interim provost, vice president for finance and administrative services, an interim vice president for finance and administrative services, vice provost for academic administration, interim vice provost for academic affairs, a college dean, and a college associate dean. These individuals were important to include in this study because all of them had the responsibility to gather information and respond to board member requests that were relevant to establishing a college of medicine during the decision-making process. Some of these administrators had consistent and direct contact with the board members throughout the process but others did not. Part of the reason for limited administrator contact during this time was because personnel changes occurred while the board deliberated about the possible new college. As a consequence, some individuals cycled into their roles later in the consideration process. Few administrators served in their roles the entire time the proposal was being considered by the board of trustees. In addition, while the president was committed to responding to every board question and request for information, he did not want to overwhelm the board with too many administrators interacting with them. Based on some data from administrators the president may have also harbored some concerns about what opinions staff would share with board members about the proposed college. 62 The Idea: A College of Medicine It is interesting to observe from the administrators’ perspectives how the proposed college of medicine was considered by the governing board. Because of their various administrative roles and responsibilities most senior administrators had differing remembrances of first learning about the possibility of the university establishing a college of medicine. Those administrators with the most direct interaction with the president indicated they first learned of the proposal from him. However, those that had direct contact with the board definitely felt the physician board member promoted the idea and was in partnership with the president in promoting it to the board and the university. “The president had the idea the university needed a college of medicine. I was not working with the board the entire time the idea was considered but my perception was that throughout the whole thing it was the physician board member and the president who promoted the idea of the new college. My supposition is the president did this to make himself much more marketable as a college president and because his father had been a doctor. The president did attend medical school for a year and dropped out. I had this sense he felt a little bit inferior because he had not become a physician.” (College Dean) This theory about the president’s personal regret that he had not become a physician as one reason the college of medicine was proposed was echoed by more than one administrator. For example, one administrator shared. “I believe the president could not afford to attend medical school but because both his parents were in health care he had an unblemished passion for medicine. He was passionate about medicine and thought a college of medicine could work at our university. I also know that the physician board member and the president did talk with a bunch of doctors outside of our home community and they thought the idea of a college of medicine was a good idea. But as to whether the president thought of it first or the doctor did I don’t know. But certainly, the physician board member was instrumental in having other physicians talking to the president.” (VP for Finance and Administrative Services) 63 Another administrator who did not regularly have contact with the board recalled that the president mentioned the possibility of a medical school in his report to the board in July, 2007 during a Board of Trustee meeting. “From a distance, it was either the physician board member or the president who promoted the medical school idea. The president was very interested and supportive as was the physician. Who was interested and supportive first? Who helped the other one? I really don’t know.” (Vice Provost for Administration) For the benefit of this study it was important to secure the president’s opinion about who proposed the new college of medicine. The president’s opinion and recollection are clear to him. “There’s no question the proposal came from me. I started the whole conversation which began casually at a lunch with the Board of Trustees. I had started thinking about a college of medicine because I saw what occurred at the University of Central Florida and at East Tennessee State University because neither one had a hospital. But those medical schools became a reality because there was such a significant need in rural communities for physicians. I kept hearing people say in [this state] they could not find a doctor. And folks in health care were also worried about a shortage. So, I was thinking about this more and more and then in 2005 a physician came on the board of trustees and he grabbed onto what I was talking about in a huge way. And former board members began to hear what I was saying and they bought into it. I told them it would raise the profile of their university and it would help with research.” (President) The president described additional reasons to establish a college of medicine and why he promoted the idea, saying: “I was deeply interested in the clinical mission. And part of my interest was seeing our physician assistant program that we started that kept growing. And I thought, you know, I feel as if we’ve already kind of gotten this started, so we just need to build on it. The problem with the medical school is it takes so much to convince people. But I rode the wave, no question that I rode the new medical school wave.” (President) One administrator recalled that the president indicated there was only going to be a limited window of opportunity to open a college of medicine. Coincidentally, the president had already built substantial financial reserves at the university as a cushion to absorb declining state funding support for the entire university and also to have resources available in case there was a 64 right opportunity to invest those reserves. In his mind and the minds of others a college of medicine seemed to be the right opportunity. Administrators and the Board of Trustees Administrators’ recollections of board reactions to discussions about the possible establishment of a college of medicine were limited. Any interactions or briefings between administrators and board members typically occurred during the informal session with the Board of Trustees prior to formal meetings because they were closed sessions. The board and administrators always had a private, informal session in order to share information and discussion prior to the formal, open meeting. No decisions were made during the informal board sessions. As a few administrators explained, “At times the president was guarded in what he wanted presented to the board,” (VP Finance and Administrative Services). Meanwhile, the Vice Provost for Administration shared, “I did not have any direct conversation with a board member in regards to a college or a school of medicine or its formation. All my communication flowed through the president. With the exception, of course, of reporting out directly to the board with the president in the room”. (Vice Provost for Administration) Internal Data Gathering Early on when the proposal was first being considered it became apparent to many administrators, who convinced the president that there was a great deal of expertise to access from faculty and staff on campus about establishing a new college. In this section some of the information gathering processes such as work groups, and the work of ad hoc committees are explored. One of the first steps the president took was to establish an informal work group to study various aspects of opening a new college. The work group was composed of mid-managers on campus representing academic affairs, finance, information technology, library services and 65 facilities. The expectation was that the group could begin to anticipate what was needed to open a new college, provide the president and the board information and help make the case for the medical school. The Vice President for Finance and Administrative Services reflected on the effort this way, “At one point, we were headed down a path and we didn’t know where it was going to go. I remember going to the president and saying we need to get some other people involved even though he wanted to be very confidential about all this. … This was an informal but very confidential work group and a great team to work with. None of us knew anything about medical schools but each of these folks had contacts at existing medical schools they could reach out to for information.” (VP Finance and Administrative Services) During this same time period the president also established and appointed a Medical School Vision Committee chaired by the former interim provost and college dean. The 12member group was composed of basic scientists, ethicists, health scientists, the chair of the academic senate as well as chief research and academic officers to advise on how best to develop a 20-year vision for the college of medicine’s academic program. The committee chair was responsible for presenting the committee’s work to the board. Other than that, he had limited exposure to the board during this time. “I presented the results of the vision committee at the informal board meeting since it was a closed session. I didn’t want to get too public because I had concerns. I had really strong concerns about operating a medical school based on certain models which I think were being considered and I did not think we could use those. I am really not sure the board looked at any of the committee work. I think they had a sense, they had the impression we could open a college of medicine. The college would cost $25 million and that’s a small price to pay to have a medical School. I don’t think they looked in detail at anything, quite honestly.” (College Dean) Besides considering data from the vision committee board members asked the work group to study the financial aspects of a new college and potential partnerships with area hospitals. Two members of the work group recalled, 66 “The questions I got from the board were how are you going to pay for this and what are the liabilities if it doesn’t work? And would the money need to be taken away from other programs to pay for this new college.” (VP Finance and Administrative Services) “From my perspective, the number one focus seemed to be on affiliation agreements to lock in partnerships between hospitals and the university. And second was curriculum and facilities. Specifically, did we have the necessary facilities because the LCME standards have some really specific requirements.” (Vice Provost for Administration) These recollections present different perspectives on how administrators viewed the governing board’s engagement in information gathering and analysis. Administrators with more direct board contact seemed to experience more substantive interaction with them than administrators who drew conclusions mainly from perceptions and possibly pre-conceived impressions. External Information Gathering Besides the internal information resources available to the board, external information sources were also provided to administrators and board members by the president and key administrators. That information was embraced by some, challenged by others but was regarded as impactful by everyone interviewed for this study. Initially, the president sought information from external sources to help validate the need for a college of medicine. He viewed himself as the visionary who initiated the proposal but realized he needed to prove the proposed college’s feasibility. “I spent a lot of time at the front end trying to determine whether or not it was something that was doable or necessary for our state. I found out with the help of the AAMC and the AMA that a medical school was necessary. There was no likelihood there would be a sufficient number of doctors at all in the eastern or northern areas of our state. At the same time when I first started looking into this, candidly, the LCME, the accrediting body didn’t even want to talk to me. But when I saw that a university out of state and a bunch of others started moving in the same direction toward developing a medical school I did the same. And that’s when the board chair and the physician board member and I visited one out of state campus and we began following their plan to establish a college of medicine.” (President) 67 During the May, 2007 visit to a medical school out of state the president and board members learned of an individual who assisted that institution in the development and planning of their college of medicine. He had served at the AAMC as a senior executive and editor of a medical journal where he had the freedom to serve as a personal advisor to universities considering colleges of medicine in a number of cases. In early July, 2007 a memo from that advisor to the president details what preparing a feasibility study about a new college of medicine would require. “The advisor was a big turning point. He gave me a paper he had written, on what medical education could and should look like. His agenda was to transform medical education as we knew it and turn it into an enterprise that focused more on learning instead of research. He was very concerned about the extent to which medical education had been viewed as research and it wasn’t training good doctors, good clinicians. He convinced me that we needed to make this a strong clinical program. In effect, I viewed him as a sort of temporary dean of medicine.” (President) During discussions with this advisor, the president began to understand that his view of a college of medicine was too broad. According to the president the advisor helped focus his thinking to really consider what would be the college of medicine’s mission and curriculum indicating, “So the foundation on which I built the school was on rural health disparities and that became our focus” (President). A number of the administrators agreed that the influential advisor’s report greatly impacted both the president and the board of trustees. Even though the advisor presented his findings to the board of trustees a couple times, administrators challenged his credentials, his background and his familiarity with the LCME requirements. Their concerns prompted them to question if board members were aware of discrepancies in the report and how the report impacted their decision about establishing a new college of medicine as noted in these two administrative comments: 68 “The advisor’s report is what I think sold the board on the proposal. Later we found out it was not quite accurate and why wasn’t it accurate? Was that really his report or was that a doctored report or was he told to make that report? It sure threw a loop in the process. There is an urban legend that either the report was altered after it was received or it was requested to be altered.” (Interim Vice Provost for Academics) “Who selected the advisor? Where did he come from and with what credentials? I don’t know. I asked the president how this advisor could tell you your college finances could just be based on tuition revenue when the LCME requirements clearly state you must have to have diverse sources of revenue? The LCME said that tuition cannot be so high the student can’t bear the debt or it drives them into a specialty as opposed to following their true interest.” (Vice Provost for Administration) Despite his stated concerns about the advisor, the Vice Provost for Administration conceded that the advisor had made some good points in his report, reflecting, “We do have a strong biology department, we have a strong library collection and we have these things that are necessary and those are good points. But he did not say we would be the first institution in the country to offer an MD degree without offering a Master’s degree or a PhD in biology at our university.” Some administrators did follow up and had discussions with individuals at the LCME who initially agreed with recommendations in the advisor’s report. However, administrators came back at a later time and clearly disagreed with a very important finding in the study pertaining to revenue sources for the college of medicine. In direct opposition to what the advisor said, the LCME clearly stated that colleges of medicine that expected to be accredited could not base their budget on one revenue source – tuition. Medical schools were expected to prove they had diverse funding sources to launch and sustain their medical schools in order to achieve accreditation. In addition to receiving and reviewing these external reports, the board was aware that administrators also engaged in conversations with some medical schools across the country already serving more rural constituencies. For example, the provost remembered, 69 “There was a dean at El Paso (Texas) who had developed a rural-based medical school model and we spoke to them as did a board member. And there was also outreach to a similar program in Washington or Oregon.” The board was also aware of ongoing discussions that took place between administrators and area hospitals to establish articulation agreements between the university and the hospitals to insure medical school students would have the opportunity to engage in hospital clinical rotations as part of their training. How Did the Board Work Together? It seems clear that both board members and administrators for the most part had the same internal and external information sources to study as they considered establishing a college of medicine. What was not clear to administrators was whether board members were discussing this information with each other or simply individually as they debated whether or not to establish a college of medicine. “They must have had discussions because there were some very focused financial questions from a couple board members as well as other questions in the informal board sessions. A lot of those questions were answered by me and the physician board member. He was a quieter member but relentless about the proposed college.” (President) “Remember me telling you about the road trips with the president to visit board members? A lot of those conversations were one to one meetings or one to two meetings. And they were to gather support for the college of medicine. So when we had these visits it was obvious that board members already had some conversations among themselves. They did a lot of talking among themselves. I recall one board member whose father was a physician and that board member became a powerful ally for the medical school. But it is also important to point out that there was some cynicism among board members about the college. Can we really do this or should we really do this? I can’t pin that to any particular person right now but it was there.” (VP Finance and Administrative Services) Decision Leaders As the board worked towards making a decision about whether to establish a college of medicine or not, there were individuals in the opinion of administrators who seemed to have significant impact on the board members. Administrators were somewhat divided in their 70 responses but for the most part agreed it was the president and the physician board member who had the most impact on the board in this case. In the words of several administrator participants, “I think the physician board member was a prime driver, probably more behind the scenes, but board member number four was right up there.” (VP Finance and Administrative Services) “The physician board member had the most influence on the board. As soon as the idea got rolling it was the physician board member’s baby. But the president was a full advocate and he wanted to insure it was the best possible program.” (Provost) “I think it was the president with the physician board member clearly a supporter. But in my opinion, I don’t know that the physician board member was an opinion leader on the board.” (Interim VP Finance and Administrative Services) “Oh, certainly the president’s influence. You know the board empowers the president and trusts the president to administer the institution. Very few authorities are reserved to the board exclusively.” (Vice Provost for Administration) A different observation came from one administrator who asserted you could determine the level of interplay and engagement during the medical school discussions based on where board members sat at the board table during meetings. “The chair at the top of the table was for the chairperson, and the physician board member sat right next to that. The distance board members sat from the chairperson seemed to indicate their engagement. I think you could determine interplay and engagement by the seating arrangement of the board at the board meeting table.” (Provost) Following up on the observations shared by administrators the president weighed in with a comment about his own impact on the board during the college of medicine deliberations. “I really do believe I had the most influence. I think they looked to me. It went from a couple of them saying, yes, let’s do this and a couple of them saying okay, well, let’s look at it and a couple of them saying, well, this will never happen. I think basically over time what happened is the ones that were the most skeptical and didn’t say it but I could see it in their faces, they came along because I think they started to realize the real value to their institution. And what it would do forever in terms of changing their institution. So, I showed them the feasibility.” (President) 71 Similar to other conclusions reached in this dissertation, administrators perceived that the president and the physician board member most likely had the most influence and impact on the governing board as they deliberated towards a decision on establishing a college of medicine or not. Reasons for the Decision Following the review of information, discussion among board members and time spent deliberating, the board of trustees cast unanimous votes in December, 2007 and in September, 2008 to proceed with the establishment of a college of medicine at their university. With all the data and internal and external input, what ultimately persuaded the board to cast affirmative votes and have the university move forward with the college proposal? On this, administrators’ opinions vary as these comments suggest. “Clearly the need for primary care physicians in central and northern areas of the state. Those data were downright scary. The projections of the number of shortages were from across the country but were especially strong in rural areas. If I recall [State’s] need was stronger than other areas. And the advisor set the table explaining what resources the institution already had and how that could help support a medical school helped.” (Vice Provost for Administration) “There clearly was a need for physicians especially in rural and northern sections of the state. And I think they thought that financially it was going to be as significant as it turned out to be. Had we not had the reserves we had we never could have pulled this off. And I think they thought it would position the institution differently. It fits in line with more of that movement to STEM and the health fields. And people look at you differently when you have a College of Medicine, a professional school of that caliber.” (Interim VP Finance and Administrative Services) “I could be wrong but the potential that the proposal could be financially feasible was important. The other really important factor was the need for physicians in the northern section of our state. That was huge. There’s a clear need. But I think it was the need and whatever the president’s motivations might have been.” (Interim Vice Provost for Academics) “I think they thought it was in the best interest of the institution but they also wanted to be the first new medical school in their state.” (Provost) 72 In the president’s opinion, it was a combination of factors that convinced the Board of Trustees to support establishing a college of medicine. “It would strengthen the institution. And when I started talking about clinical experience and making more doctors available to poorer populations in our state, they realized that I was on to something.” (President) Decision Making Process University governing board members are expected to make decisions regularly at board meetings but it is not often they consider establishing a new college, especially a professional college such as a college of medicine. As this board of trustees contemplated this transformational change for their university did administrators feel the decision making process was similar or different to other processes the board followed relative to more typical decisions they were asked to make. These comments suggest administrators observed similarities and differences in this decision-making process. “It had similarities but it was also different. In this case I knew there was a lot of background chatter among board members. But they knew in public board meetings they would be united. So, it might be a little ugly, how they got there, but they were going to put a good public face on it.” (VP Finance and Administrative Services) “I think it was similar insofar as collecting information, hearing about it, sharing it, and considering it. It’s not like this decision was a one-shot deal where under the cover of darkness, they snuck the decision in. It was brought up and mentioned several times.” (Vice Provost for Administration) “I didn’t notice any changes in discussion or processes toward decision making. But one thing was different. For a while the board established a college of medicine standing committee where the board received updates on buildings, fundraising, affiliation agreements, and research.” (Interim VP Finance and Administrative Services) One administrator’s impression was unique from the others expressed. “The decision-making process was similar and different because there was a board member who was such a cheerleader for the proposed college. The board in 2007 really was not a questioning board. It was a rubber stamp board for the most part. This is my point of view and different people will have other points of view.” (College Dean) 73 A reason to better understand the decision-making process was to learn if the governing board pursued a noticeable or more unique path to a resolution than was typical in their day to day board work. For the most part, the road to a decision seemed similar to ones traveled before because of all the information they requested and studied. However, administrators suspected that this time there was more informal discussion among board members about the proposed college, the board was determined to take ample time to study and review the data gathered, they initiated an ad-hoc board committee to only focus on the proposed college of medicine and there was an active and vocal advocate for the new college on the board. As a result, administrator insights suggest that other than asking questions, and pursuing a great deal of information this decision making process was different for the governing board. No doubt this was because they realized the significance of a possible decision to establish a college of medicine. Lessons Learned Once the decision was made to establish a college of medicine and with the benefit of time it is informative to learn what administrators would have done differently or recommended during the decision-making process if given the opportunity. Some administrators admitted they would have been more comfortable if they had better budget projections for the new college costs for the first few years. Others felt the process could have and would have been improved if the project details had been made more available to more members of the university community. “I think we could have been more transparent with the details. I think we should have had more of a deliberate campaign to sell the idea of the medical college internally within the university. We could have and should have sold it better.” (Vice Provost for Administration) And finally, from the president, “I wish I had drawn more of a map for the board. Again, you can only know what you know at the time and much of that map, you could only fill in as you went. But I really do wish that I had had a map to show the board about how long it would take to establish the 74 college and what it would take. For a lot of people a map could help give them a sense of how things could play out.” (President) Following this analysis of the study findings from the board of trustee members and university administrators, the discussion chapter explores how the various frameworks of decision making helped to clarify and explain the Board of Trustee decision to establish a college of medicine at their institution. 75 Chapter Six: Discussion of Board of Trustee and Administrator Findings The purpose of this case study was to analyze how university governing boards make decisions about complex issues. Specifically, this study focused on how a board of trustees decided to establish a new professional college at their institution - a college of medicine. Taken into account were governing board reflections as well as those of key administrators who participated in the decision process at that time and a review of key institutional documents that could shed light on board decision making. Like any voting body, a governing board has a variety of options available to them. They can reject, accept, modify or ignore proposals or ideas. Yet, any of these possible responses have something in common. Each requires that a decision about which course of action to follow be made. When the board of a comprehensive university in the midwest was presented with the idea to open a new college of medicine, they did not initially reject the proposal. Instead, while recognizing the enormity of making such a decision, the board understood a thorough study of the proposal was necessary. They were both willing and capable of engaging in such a thorough analysis but at the onset they may not have realized how long or detailed such a review needed to be. To better understand the process the board experienced, three research questions drove my exploration of governing board decision making to better explain how they could make this decision: 1) What factors influenced board member decision making? 2) How did board members seek input when considering a proposal of such transformational change? 3) Who did board members seek input from when considering the proposal to establish a college of medicine? Data for this study came primarily from interviews with governing board members and 76 university senior administrators at a comprehensive higher education institution that established a college of medicine following years of study and deliberation. Despite what the literature might suggest was important, the real focus of this study is on board member responses instead of administrator opinions and reactions. Ultimately, it was the governing board that had the authority to make a decision about establishing a new college and it was most appropriate to pay more attention to their impressions of decision making. However, the results of all the interviews, including those with key administrators involved at the time and a review of key institutional documents, inform this discussion section. I utilized three theoretical frames (stewardship, strategic choice and socialization) to interpret the methods governing board members used to deliberate and reach such an important decision. Based on the literature review, the three theoretical frames used all seemed applicable to the focus of the study. Bastedo (2006) asserted there should be more research about higher education policy, governance and the politics of higher education as higher education continues to evolve. Thus, he predicted there would be more and varied theories applied to the study of a numerous higher education research topics. Throughout this study I realized that more than one theoretical frame would be useful to interpret board motives and actions because governing boards are complex entities as are the decisions they are asked to make. As mentioned I used a combination of stewardship, socialization and strategic choice theories to analyze governing board decision making in this case study. Drezner and Huehls (2014) assert stewardship theory is best applied to university governing boards when boards expect presidents to lead and manage their institutions free from interference. The majority of these board members’ responses suggested a strong inclination to allow their president to manage the day to day operations of their university. Miller and 77 LeBroton-Miller (2006) remind us that another tenet of stewardship is when board members act altruistically to benefit the organization because they identify with the organization and its objectives. Their altruism helps establish a collaborative relationship among governing board members and university administrators. Strategic choice theory as explained by Chandler (1962) suggests that having a strategy allows for the establishment of long-term goals and courses of action to carry out those goals or strategic choices. The board member interviews included numerous examples of this type of long-term planning. As information gathering and interviews concluded both of these theories were useful in understanding how a governing board reached decisions. Socialization theory recognizes the important role social relationships can play to increase learning and improve performance, leading to shared understandings among individuals, even board of trustee members (Nahapiet & Goshal, 1998). I expected that a small, eightmember board would have relied on each other more for information and support than was expressed during the interviews. Strong, interpersonal relationships only seemed to exist among a few board members and were limited to board interactions. I analyzed the study data through the lenses of the three theoretical frames to better understand the information gathered and they were helpful. But at the conclusion of the data gathering and analysis phase of this dissertation it was apparent, if somewhat surprising, that the stewardship and strategic choice frames were far more applicable to this board’s decisionmaking process than was socialization theory. Stewardship Theory The focus of stewardship theory is on the strategic role a governing board plays. The theory is expansive and spells out board motives for achievement and recognition, successful 78 plans, and strong stewardship of assets and loyalty to the institution (Muth & Donaldson, 1998). Throughout the study of how a governing board made such an important and impactful decision about establishing a college of medicine it was reassuring to hear each participant’s expressed commitment to serving as a good steward of their university. Admittedly being a good steward has different meanings for different individuals. But overall commitments to fiscal responsibility, meeting the university mission and protecting the university for long-term viability were expressed repeatedly. This group of board members seemed aware of their stewardship responsibilities to the university and attempted to exercise them to the best of their ability. As an illustration of this overall commitment to stewardship, a board member indicated he questioned the value of establishing a college of medicine even after the board voted in support of the proposal. But even with this expressed skepticism he summed up his and board deliberations this way, “When the board makes a decision, we consider all the aspects we possibly can and ultimately, we make our decision based upon what’s in the best interest of the university.” (2nd board member) Another board member spoke about the board always working to keep the university mission intact and ideas were always evaluated with that in mind stating, “I have been on other boards that were more ceremonial. But this was an effective board. The governance of our board was well run. And the administration and staff always gave us information. This board always held itself accountable and was very aware of outcomes and considered how students and the community would be impacted.” (7th board member) An additional comment that reflected strong stewardship was expressed by a board member who indicated the board knew they were responsible for moving the university forward in a positive and responsible way. In this member’s opinion, they insured forward momentum when strong fiduciary decisions were made as well as good decisions that could affect the 79 university’s core mission. A final reflection on stewardship was offered by a board member who explained, “Your job as a board member is to do what’s the best for the university, its students, its alumni, its faculty and all the other stakeholder groups that help make the university successful.” (1st board member) Board members’ commitment to quality stewardship also provided them opportunities to think about the university and its future in a strategic manner and make decisions that could help prepare the institution for a strong, viable future. Strategic Choice Theory Due to the board of trustees’ commitment to being good stewards they could also consider strategic choices beneficial to the university that would have long term impact. Due to the board’s strong stewardship and that of prior governing boards at this university, the board had more flexibility and freedom to consider their university 10, 20 and 30 years hence. For example, if the board had to continually negotiate how to keep the doors of the university open they would not have been free enough to consider the university’s future. At the time, the governing board was considering establishing a new medical college, the university was financially sound. An example of how the board recognized they had the ability and the responsibility to plan strategically for their university is best explained by the physician board member. Earlier in this dissertation he recalled when he was first appointed to the board and given a five-year vision plan to review. In reflecting, he did not think there was anything “earthshaking” in it. At about the same time the American Association of Medical Colleges (AAMC) announced there was a significant shortage of physicians across the U.S. and the shortage was growing. As a result, the AAMC called for a 30 percent increase in the number of medical school students. Following that 80 AAMC pronouncement, the state’s professional medical society also identified a shortage of approximately 6,000 physicians in the state of this case study especially in more rural areas. The physician board member indicated that the combination of these state and federal data prompted him to conduct further study. “I did a tremendous amount of research on medical schools with that information in mind. While our state is about the eighth largest in the country it ranks about 36th in medical school enrollments. From that I determined that our institution should begin to explore the possibility of opening a college of medicine.” (5th board member) This is an obvious example of a strategic choice that could alter the future of the university. Additionally, another board member expressed support for establishing a college of medicine to address the existing and growing physician shortage when he realized that endorsing such a proposal would be a strategic decision with long-term impact on the future of the university. He readily admitted the decision also carried with it some secondary benefits such as enhancing the reputation of the institution by establishing a medical school. And he had expectations that a new college of medicine could also be helpful to the existing health profession programs at the university. “You know we were fortunate. We made this very important strategic, history making decision with little controversy and criticism. Overall, we were fortunate.” (1st board member) Strategic choices are rarely made without concern and questions expressed by other constituencies. That was also true in this case. Some board members seemed more aware of these circumstances than others. But even those aware of some hesitancy on campus about establishing a new college of medicine did not view the objections as insurmountable. The long-term benefits and impact of this strategic choice outweighed the concerns. 81 Socialization Theory As mentioned, I expected to observe and hear about governing board socializing experiences among the eight board of trustee members that would impact this decision- making process. However, there were few examples volunteered by board members to analyze. Socialization theory focuses on the importance of social relations and developing networks based on respect and friendship (Nahapiet & Ghoshal, 1998). This board was not at war with each other and even with limited socializing with each other they were still able to navigate, negotiate, reach conclusions and make decisions, even of the magnitude of establishing a college of medicine. This is evidenced by their comments and board meeting minutes. But at the same time these board members did not appear to have developed personal friendships or relationships beyond their university board work. For the most part, they studied and considered the proposed college of medicine independently with only a few limited relationships that developed between board members. One board member commented that he had enjoyed serving on the board a few years earlier prior to the board that was the focus of this study because at that time it was full of bright people who had great business minds. “But as board members were appointed who were more political and less business astute, we started having more disagreements. And it was harder to get things accomplished,” (2nd board member). Despite this reaction most other board members thought individual board members could and did work together. Some found a board member or two they relied on to know more about a topic and trusted their expertise. As one member shared, “On a governing board you have people with diverse experiences, diverse skills, knowledge and perspectives. So, we all had a different way of viewing things,” (1st board member). 82 One board member commented it was the best board he had ever served on because everyone was so nice and the board was the most fun he had ever experienced because of the people. This board member had served on professional boards that tended to be quite contentious, sharing, “Instead of having factions emerge if people agreed or disagreed, we would stop and figure it out.” (3rd board member). These differing opinions from board members about how the governing board functioned suggest there was limited socializing or professional networking amongst them. Examples of how this board engaged in a space separate from board interactions are not as prevalent as expected. So, the theory does not seem as applicable as did stewardship and strategic choice for understanding the data gathered in this study. Even so, it is important to note that a governing board is still capable of making transformative and strategic decisions even without having strong social relationships among board members. These three theories provided applicable frameworks through which to analyze many board of trustee comments and insights about their decision making. Reaching a Decision Beyond the important role theories play in analyzing decision making it is also useful to consider responses to the three research questions posed to better understand board member decision making. Specifically, what factors influenced board decision making; how did board members seek input from others while deliberating; and who did board members rely on when considering the proposal to establish a college of medicine? I considered both board member responses to these questions along with administrator comments and insights to better explain this decision-making process. Key administrator comments and insights from written documents 83 were important to take into account. However, my main focus was on board member responses as related to answering these research questions. Studying the process of decision making is often as important as the decision itself according to Chaffee (1983). Chaffee argues the focus should be on the process used to make a decision instead of focusing on the substance of a decision. The assertion is that understanding the process better explains the how and why of a decision. Influential Factors After reviewing governing board member interviews, it seems what influenced the decision to establish a college of medicine the most was the interest and commitment to educate and train physicians to provide care in underserved areas of the state. It was the case made initially both by the president and the physician board member. The president recalled, “I kept hearing people say in many areas of the state that they could not find a doctor. And folks in health care were also expressing concern about a physician shortage.” (President). The university’s long-standing commitment to meeting societal needs was set in motion over 100 years ago. Some board members mentioned realizing that historically the university was first established to meet another need in the late 1800s to educate and train teachers to address the teacher shortage in the state. Establishing a college of medicine to address the physician shortage seemed to be as challenging an undertaking but also seemed to be the right decision to make given the university’s mission and role in the state. “Another important factor was the need for physicians in the northern part of the state. That was huge. There was a clear need. So, I thought it was the need and whatever the president’s motivations might have been that influenced the board.” (Interim Vice Provost for Academics) A few members of the board acknowledged that an additional benefit of establishing a college of medicine could be enhancing the reputation of their university. 84 “I think the institution wanted to be thought about like other universities in the state that already had medical schools. That may have had something to do with this proposal.” (2nd board member) “I did tell the board a college of medicine would raise the profile of the university. I also told them it would help with research which as you know from day one was my big thing. I felt the research was an important part of the university’s mission. And it would give us more credibility in the State Capitol and that would help us a lot. But I was also deeply interested in the clinical mission of a medical school.” (President) Many scholars argue that higher education institutions often mimic other institutions because they are pursuing higher prestige for their university (O’Meara, 2007; Toma, 2012). Some pursue prestige by offering the same programs and activities as those offered at institutions with higher rankings than their own and outside their traditional offerings (O’Meara, 2007). While it seems clear from a few board member comments included earlier in this section there was recognition that establishing a college of medicine could enhance the university’s reputation, it did not seem to be the significant factor in their decision making that some administrators thought. In fact, some board members seemed almost so overwhelmed by insuring the university had the resources, and the wherewithal to establish a new professional college that prestige seemed the furthest thing from their consideration. How the Board Sought Input When the board began to study the idea of establishing a college of medicine they began to gather information to consider such a proposal. “One of our responsibilities as a board is to ask good questions. I think it is healthy and that’s really what we ought to be doing. So, there was that interplay on the board at that time.” (1st board member) Some detailed examples of information that came from within the university as well as external to it are in the board of trustee findings section of this dissertation. As one board member recalled, gathering information was especially important because of the lack of knowledge from 85 both the governing board and administrator perspectives about how to open a new, professional college. As one board member observed, “It would not be good for the university not to do this right. But I didn’t see anyone around the table who had ever been on a committee or a board that opened a medical school.” (3rd board member). To begin to gather the information and insights they felt necessary to make a decision initially, there was interaction with a newly opened college of medicine in another state encouraged by two board members; commissioning a feasibility study; organizing a medical school vision committee composed of faculty and administrators; and establishing a board of trustees ad-hoc medical school committee that reported directly to the board. An additional external study was commissioned to provide an even more thorough analysis than the feasibility study on what medical school accreditation requirements included and to help determine whether the university was capable of meeting those requirements. Finally, a number of board members sought input from practicing physicians they knew personally, family members and even former board of trustee members. For the most part, all these sources of information led to more questions and required more study by governing board members. Whom Did the Board Consult? Board members read information and listened to a variety of sources as they sought input. As mentioned earlier one of the first steps in information gathering was commissioning a feasibility study by an advisor from outside the university who had guided other institutions considering establishing a new college of medicine. One board member remembered, “The author of the feasibility study was an outside source who I didn’t believe had any personal gain to make so he was more objective.” (6th board member). 86 One board member enthusiastically shared reactions to information that was collected throughout the board’s decision-making timeframe but especially from another university that had recently opened a new college of medicine in another state. “The new medical college we met with told us what to watch out for, what to be careful about, what to do, what not to do. And how to avoid mistakes we probably made anyway.” (1st board member) Another recalled the following regarding information gathering of the board and its importance for this particular board’s decision making, “I have served on boards where people rubber stamped things, where people did whatever the executive director or president or whoever the chief executive was, they would just rubber stamp it. That’s not my personality to just accept what I am given as something I need to agree to. At the same time, you have to trust the executives you are working with for their unfettered and truthful depiction of any issue you are considering, not just the issue of a new college of medicine.” (4th board member) Board members were candid when explaining which individuals, arguments and information had the most impact on their decision to establish a college of medicine at this university. Each board member reacted differently to the written reports, campus input, external input and other sources but because of their willingness and commitment to try to address the existing and growing physician shortage in the state, they all ultimately agreed to establish the new college of medicine at their university. Earlier sections of this study detailed findings from board of trustee member and senior administrator interviews. Then I explored how the use of theoretical frames helped decipher and explain some of those responses and the impact frames had for analyzing individual memories and responses to questions. As a result of these data, in the next section I draw some conclusions about how governing board members appear to make complex decisions for their university. 87 Chapter Seven: Conclusions When I began this study about governing board decision making I was not sure what I would learn. Most decision making seems to be straightforward and the result of a decipherable process. However, I did not know how a university governing board would make a decision of the magnitude of establishing a college of medicine at the university they were serving. I know university governing boards are expected to regularly decide various questions that include but are not limited to selecting and evaluating presidents, setting tuition levels, endorsing the student profile, deciding questions about the campus physical plant as well as appropriate expenditures for deferred maintenance or new facilities and strategic plans for the institution (Association of Governing Boards of Colleges and Universities, 2014). Another recent study tracking the experience of newly appointed trustees identified the three issues those board members expected to be the most involved in were, evaluating the president, budgetary and financial oversight, and strategic planning for the institution (Zeig, Baldwin & Wilbur, 2017). Establishing a new college requires consideration of the university’s long-term planning, meeting the institutional mission, and determining if there are the appropriate internal and external resources necessary to launch a new college. In other words, the why and how of deciding to accept or reject such a project. Most likely deciding to open a medical school would not be a decision made quickly or without due consideration. The data for this case study are the result of interviews with governing board members who served on a comprehensive university board in the Midwest that decided to establish a new college of medicine. This particular case was studied to determine how a board of trustees was able to navigate a decision-making process and in the end, endorse such a transformational decision for their university. 88 I have been in professional positions where I served as a member of a university President’s Cabinet, and I am a former governing board member myself so have been an observer of university boards for some time. Those experiences provided me opportunities to have close working relationships with governing board members and I observed how boards operated and functioned. And obviously, in this case study I already knew that the board had supported the establishment of the new college. From my observation perch, I expected that once the board heard about a proposed college of medicine, they both individually and collectively would seek as much information as possible before embracing or rejecting the idea. They lived up to my expectations. Board members began to gather sources and information to better understand the proposed medical school and inform their decision. But data showed university administrators were convinced that the governing board members had been manipulated throughout the decision-making process by the president and his consultants into supporting the idea of a new college of medicine, or worse yet, were rubber stamping whatever the president proposed. These same administrators concluded that opening a college of medicine would enhance the president’s professional portfolio. Again, as an observer of governing board processes I realized this president or any president could benefit from being recognized as someone able to lead and work with a governing board to make such a significant decision for a university. However, I also recognized from the data that the president of this university was passionate and committed to establishing a medical college to address a physician shortage in the state. Many of the university administrators who participated in this study, while tasked with identifying and pursuing more information or gathering it for the president and the board, did not have close or consistent working relationships with the board of trustees. Without direct or 89 continuous interaction they did not have the benefit of always understanding or appreciating board insights or motivations. Instead the president and only a few key administrators served as the points of contact with the board. While the original idea to establish a medical school may have come from the president or the physician board member or both, the governing board did not turn the ultimate decision over to either of them. Instead, a great deal of internal and external information, written and verbal, was sought by board members. Even with this information the board was discerning enough to harbor some skepticism about the proposed college and the information they received. When the board had doubts they sought additional information to either validate their concerns or provide another perspective. That information combined with board member conversations made enough of a compelling case to the board members that they eventually voted unanimously to establish a college of medicine. The preponderance of data I collected from the board indicated they kept revisiting and studying statistics about the current and future physician shortages in their state. Ultimately, being able to meet an already existing and growing need to educate and train more physicians to practice medicine in their state, especially in underserved areas, had the most impact on their decision to establish a college of medicine. Additionally, the board’s awareness and recognition of comprehensive universities’ missions helped inform their decision because a medical school was viewed as an extension of their mission. As mentioned earlier by Henderson (2009), comprehensive universities are often referred to as the People’s Universities because of their accessibility, affordability, diverse curriculum offerings and commitment to public service. These institutions address societal problems and needs through their academic programs, and helping enhance the local economic development environment (Henderson, 2009; Lynton & Elman, 1987). Thus, in making the 90 decision to establish a college of medicine, the board adhered to these perceived institutional imperatives. Not unexpectedly an additional benefit of opening the new college for a few board members was to enhance the profile of their university. But it was a secondary factor at best. Again, I believe the most influential factor that impacted the governing board decision was the benefit of opening a new college of medicine to train more doctors to practice medicine in their state. While the governing board was able to make a decision together there was still distrust and tension that developed among some board members and between some of the board and the president. Again, as someone who regularly interacted with boards and a board observer as part of my professional responsibilities, I was not completely surprised by the lack of trust expressed by some members during interviews. The data confirmed this was a strong, intelligent and discerning governing board with firmly held personal opinions and convictions. Despite that tension what surprised me was that the board still had the ability to work through their differences with each other and the president, rise above their distrust, and reach a unanimous decision of such magnitude as opening a new college of medicine. This example of decision making serves as an important reminder that probably few decisions are made with complete or total support from a governing body even if the vote is unanimous. Decisions may be more authentic if those voting still harbor some doubts and questions rather than superficially voting affirmatively in order to move on to other issues. As a result of this case study that revealed governing board insights and input I am even more confident this was not a board that rubber stamped administration proposals or ideas. In fact, if this had been a board that simply embraced a president’s proposals it seems unlikely that they 91 would have remained committed to their decision to open the new college when the president announced his resignation to accept another presidency just six months following their unanimous votes. The board members expected the president who shared their interest in opening the proposed college of medicine would be present to successfully establish it. When it was obvious that was not going to be the case the board persevered because of their own commitment to the new college of medicine. They continued to move their ideas forward with guidance and assistance from the interim president. The board interview data also make clear that boards with intelligent, self-aware members who bring different backgrounds and perspectives to the board table are capable of actually making substantial decisions instead of side-stepping or avoiding them. University administrators and presidents who prefer boards to rubber stamp all their proposals should be more receptive to and embrace boards who are capable of thinking about the university in different ways and work more closely with them as collaborators instead of as adversaries. Another more traditional view of governing boards was challenged in this study. It is expected that the chair of the board plays the primary role in determining which proposals and possible agenda items will be considered by the entire board. In this case study about decision making I saw something a bit different. While the board chair was an early supporter of the proposed new college, the physician board member played a more visible role and more persistently promoted the idea of a college of medicine to his fellow board members, administrators and anyone else who would listen. While that was acceptable to the board in this situation, it was not a typical role for one board member to play. And in the end, he still only represented one vote on the board. 92 An additional observation from the study was that this board did not experience much, if any, socializing outside of their formal university or board interactions. If there had been more socializing among these board members leading to more personal networking and shared understandings there likely could have been less tension and more trust among members. But there was not and there did not seem to be much appetite for it, either. Even so, there appeared to be respect among members for the various strengths and perspectives they each brought to the board. That combined with their personal commitment to their board responsibilities allowed them to make such a bold decision as opening a college of medicine. Implications for further study This case study helped me, and hopefully others, better understand the how and why of board decision making. But it also made me think about a variety of other questions relative to governing boards that deserve further study. For example, what is the impact on boards if they do spend time together away from their formal board responsibilities establishing networks based on respect and friendship? Do their interactions change in ways that are beneficial to the institution they serve or do more personal relationships not have an impact on board effectiveness as some authors suggest? (Nahapiet & Goshal, 1998). That information could benefit board leaders and university administrators who want to encourage the most effective boards serving their university. This study has also made me ask what role board members’ individual personalities play in decision making. To better understand a board’s decisions, studying the individuals, their backgrounds, and the perspectives they bring to the board may help better explain and clarify what positions they may be more inclined to embrace as board members. Additionally, trying to then understand if and how individual personalities form a group dynamic could help better 93 explain how a board operates and makes decisions. Group dynamics are the activities, processes, operations and changes that can occur in groups of any size (Forsyth, 2009). What sort of group dynamics develop on boards composed of individuals who likely do not know each other when they are appointed to a governing board? And is studying group dynamics helpful to develop a better understanding of how board members make decisions? Recognizing the importance of understanding board members’ personalities and the group dynamics that develop leads to a need to better appreciate the board appointment process. This case study reinforces that governing board members play a key role in deciding a university’s future (Zeig, Baldwin & Wilbur, 2017). Having a better understanding of whether appointments are politically motivated, driven by personalities, or the result of the consideration of potential board members with diverse backgrounds or skill sets could be useful when studying boards and how they function. This research also made me wonder if anyone can influence board appointments? If so, how? It seems that potential appointments could be impacted by university presidents, current governing board members, alumni or others which could in turn affect decisions made and in the end, impact the future of the university. It would be useful to study and better understand the appointment process. I do wonder if those responsible for making governing board appointments discuss what considerations and individuals influence that process. If those responsible for making board appointments are unwilling to be forthcoming it will be more difficult to study. This study also reminds us that the governing board members all served on the board for varying lengths of time while they analyzed and finally voted to establish a college of medicine. The board studied the proposed college over a number of years during which some board members’ terms concluded and they cycled off the board and new appointees replaced them. 94 Thus, studying the onboarding and/or orientation processes for new board members and what was included would be helpful when considering decision making by boards with staggered terms. Regardless of how board members end up on governing boards or how long or short a time they serve, the onboarding and/or orientation processes the university uses with board members becomes critically important. Clearly this is an important area to analyze and understand. Zeig, Baldwin and Wilbur’s (2017) study of newly appointed board members indicated that board orientations typically consisted of presidential staffers and administrators talking at them and telling them only what they wanted board members to hear. According to those study participants the senior administrators spoke about what they did on a daily basis rather than engaging in any kind of a discussion about university strategy. My current study reinforces the importance of substantive onboarding processes that should go beyond what Zeig, Baldwin and Wilbur found, taking on a higher level of importance especially if an institution is considering an issue as impactful as establishing a new college of medicine. Additionally, the staggered terms of this governing board serves as another reminder of how important onboarding processes and retreats are for members and thus an important area for further study. Interviewing current and former board members could provide valuable insight into how best to structure those orientation sessions. The results of this case study suggest that such sessions should at the very least focus on the board’s stewardship responsibilities along with reinforcing board member’s commitments to the university and the state. Some who participated in the Zeig, Baldwin, Wilbur (2017) study expressed interest in continuing education for board members in the form of retreats or sessions organized to discuss specific issues relevant to the university. 95 This dissertation is a representation of how this governing board was able to make an important decision for their university from the perspectives of those involved at the time but that does not mean their decision-making process is applicable to the study of other university governing board decisions. Applying the tenets of stewardship and strategic choice theories to the theoretical study of decision making were appropriate in this case. Whether these theories are as useful when applied to larger governing boards, elected boards or boards at private institutions decision processes is not known. It would be useful to study decision making within these other board environments to compare and contrast findings and to identify the applicability of those theories in other circumstances. Before conducting my case study, I was convinced that applying socialization theory to board interaction would play an important role in understanding how a small, eight-member board could work towards making a transformational decision for their university. The term socialization has many different definitions in academic literature. Socialization theory could be interpreted as having influence over others. That could have been applied to the influence that the physician board member and the president had over some board members. Additionally, there was influence some board members had over one another if they had a respectful relationship and trusted each other. However, my research focused on socialization as socializing that I expected would occur among board members. Such socializing could help build friendly relationships and trust among board members most likely leading to easier decision-making. In this case that definition did not apply. There was little appetite among this board for socializing that could have built stronger board relationships. However, I believe socialization is still an important and relevant theory to examine further in addition to other theories that could be applied to better understand governing 96 board decision making. Some other useful theories for studying board interaction and decisions include principal/agent theory (Caers, DuBois, Jegers, DeGierter, Schepers, & Pepermans, 2006; Muth & Donaldson, 1998), social network theory (Valente, 1996), and institutional theory (Bastedo, 2009). Summary In summary, I believe the decision to establish a college of medicine was the governing board’s own decision following extensive study and deliberation. The college proposal was presented at an opportune and appropriate time to an intelligent, discerning board that realized opening this college could help address an important, if not critical need in the state for more trained physicians. And helping address that societal need was recognized as part of the university’s mission to offer programs that had met other societal needs in their state throughout their history. In addition, the university appeared to have, if not all, most of the resources necessary to launch a new college. Those reasons combined with the support of many external constituencies who had advocated throughout the decision-making process for a new college of medicine to train and educate more physicians for the state, especially to serve in underserved areas, informed the governing board’s decision to establish a new college of medicine at their university. 97 APPENDICES 98 APPENDIX A Interview questions for former Board of Trustee members. 1) 2) 3) I would like to begin with knowing whether you were employed and in what capacity when you served on the board. How did you come to serve on the board and why were you interested in serving? Before serving on the Board what did you think it meant to serve on a university governing board? a. Once you began your board service in what ways, if at all, did your opinion about the role of the board change? 4) 5) 6) Observers expect boards make a variety of decisions about the university. Do you agree or disagree? Tell me about the kinds of decisions you made during your board tenure, not specific decisions but the nature of those decisions. a. What factors did you take into account when making decisions? From whom did you seek input, if anyone (other board members, members of the university administration, external sources)? Did this vary depending on the decision being considered? Now I would like to focus on the specific decision to establish a college of medicine and how the board made that decision. 7) 8) 9) 10) 11) 12) 13) How and when did you first learn of the proposal to establish a college of medicine? In your opinion what was the motivation or goal behind the proposal? Tell me about the process the board went through to make the decision to establish a college of medicine. For example: a. How did you as a board member seek information to educate/guide your decision making? b. Who did you seek input from? c. How long did the board consider the proposal (years, months, overnight)? Please share your best recollections about how the board ultimately decided to establish a college of medicine. In your opinion was this decision-making process similar to processes used to make other decisions by the board? If it was different, why was it and in what way? Is there anything else you think I should know about how the board made decisions when you served on the board including the decision to establish the college of medicine? Are there others you recommend I speak to about the university proposal or decision to establish a college of medicine? 99 APPENDIX B Interview questions for university administrators. 1) 2) 3) 4) 5) 6) 7) 8) What was your role at the university when the Board of Trustees decided to establish a college of medicine? How were you engaged with the Board of Trustees when they considered establishing a college of medicine? Tell me the process you believe the board used to make the decision to establish a college of medicine. 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