Renovating medical education in a changing vietnam

MOVING THE MOUNTAIN:

RENOVATING MEDICAL EDUCATION
IN A CHANGING VIETNAM




Luu Ngoc Hoat




MOVING THE MOUNTAIN:

RENOVATING MEDICAL EDUCATION
IN A CHANGING VIETNAM

Luu Ngoc Hoat

ISBN: 978-604-66-0001-5
Front cover illustration:

Photograph of the main building of Hanoi Medical University, the institution that
led the process of change in medical education in Vietnam, with the support of the
Ministry of Health, Ministry of Education and Training and the Netherlands-financed

project. The building was completed in 2002 but in the style of the original
university established 100 years earlier.


VRIJE UNIVERSITEIT



MOVING THE MOUNTAIN:

RENOVATING MEDICAL EDUCATION
IN A CHANGING VIETNAM






ACADEMISCH PROEFSCHRIFT

ter verkrijging van de graad Doctor aan
de Vrije Universiteit Amsterdam,
op gezag van de rector magnificus
prof.dr. L.M. Bouter,
in het openbaar te verdedigen
ten overstaan van de promotiecommissie
van de faculteit der Aard- en Levenswetenschappen
op dinsdag 25 november 2008 om 10.45 uur
in de aula van de universiteit,
De Boelelaan 1105

door

Luu Ngoc Hoat

geboren te Nam Dinh, Vietnam


promotoren: prof.dr. E.J. Ruitenberg
prof.dr. G.J. van der Wilt
copromotoren: dr. E.P. Wright
dr. J.E.W. Broerse






“Nếu kế hoạch một thì quyết tâm phải mười và biện pháp phải hai
mươi.”
“If the plan is one, the determination must be ten and the measure
must be twenty.”

Ho Chi Minh

The first President of Vietnam
Members of the Thesis Committee:

• Prof.dr. J.C.C. Borleffs, University Medical Centre Groningen
• Prof.dr. J.F.G. Bunders, VU University Amsterdam
• Prof.dr. F. Scheele, VU University Amsterdam
• Prof.dr. Truong Viet Dzung, Hanoi Medical University



TABLE OF CONTENT

Chapter 1: Introduction 1
1.1. Aim and purpose of the thesis 1
1.2. Theoretical Background 2
1.2.1. Medical education development 3
1.2.2. Management of change 5
1.3. Research design 17
1.3.1. Main objectives and research questions 18
1.3.2. Brief case description 19
1.3.3. Research methods 21
1.3.4. Research validity 25
1.3.5. Research team 27
1.4. Outline of the book 27

Chapter 2: The context for development of medical education in Vietnam 37
2.1. Health system in Vietnam 37
2.2. Human resources in the health system 40
2.3. Health indicators and changing disease patterns 44
2.3.1. Health indicators 44

2.3.2. Changes in disease patterns 46
2.4. Development of medical education in Vietnam and need for intervention. 47
2.4.1. Colonial occupation by France (1886 – 1945) 48
2.4.2. Wars with France and America (1945 - 1975) 49
2.4.3. After the wars but before innovation (“Doi moi”) (1975 – 1985) 50
2.4.4. After innovation but before the intervention of a Dutch project for medical
education (1986 – 1994)
50

Chapter 3: Medical education changes with support from an international
project
55
3.1. Situation analysis at the beginning of the project 55
3.2. Main objectives, strategies and activities of the first phase of the project. 59
3.3. Main objectives, strategies and activities of the second phase in comparison
with the first phase of the project
67


3.4. Changes along the way: revision of plans on the basis of experience during
implementation
74
3.5. Limitations of the project in medical education development and efforts to
overcome them
76

Chapter 4: Constraints, challenges and lessons learned of the first phase of
the project
85
4.1. Obstacles to the introduction of change in the medical schools 85

4.1.1.Isolation of Vietnam and its medical schools until recent years 85
4.1.2. Lack of standards for medical doctors as end-points for medical training 86
4.1.3.Low status of public health in medical schools 86
4.1.4.Time constraints 87
4.2.Constraints and obstacles in project implementation 88
4.2.1.The understanding between the four medical schools and KIT 88
4.2.2.Misunderstandings after Workshop 1 on curriculum 90
4.2.3.Conceptual differences 91
4.2.4.Identification of indicators for project monitoring 91
4.2.5.Sustainability 93
4.3.Lessons learned 93
4.3.1.Language 94
4.3.2.Balance between motivation and sustainability 94
4.3.3.Time 95
4.3.4.Strengths and weaknesses of the schools 95
4.3.5.Future developments 96

Chapter 5: Participatory identification of learning objectives in eight medical
schools in Vietnam
99
5.1. Introduction 99
5.2. Project aim 101
5.3. Methods to identify learning objectives (needed KAS) 101
5.4. Results of the steps in the process 102
5.4.1. Step 1: Inter-school workshop on KAS process 102
5.4.2. Step 2: Policy documents 103
5.4.3. Step 3: Formulation and selection of KAS topics 103
5.4.4. Step 4: Teaching staff contributions 105
5.4.5. Step 5: Achieving consensus 106
5.4.6. Step 6: Skills levels 106

5.4.7. Step 7: KAS survey 107
5.4.8. Step 8: Final KAS book 107
5.5. Difficulties with key concepts 107
5.5.1. Distinguishing among knowledge, attitudes and skills 107
5.5.2. Selecting the problems and issues for KAS lists 108
5.6. Coordination system 108
5.7. Discussion 109
5.8. Conclusion 111

Chapter 6: Practicing doctors’ perceptions on new learning objectives for
Vietnamese medical schools
115
6.1. Background 115
6.2. Methods 117
6.2.1. Study design 117
6.2.2. Study participants 117
6.2.3. Data collection tools 117
6.2.4. Qualitative data 119
6.2.5. Data analysis 119
6.3. Results 119
6.3.1. Key characteristics of the study population 119
6.3.2. Relevance of skill levels set by teachers and perception of the practicing
doctors
120
6.3.3. Frequency of using selected skills according to discipline 122
6.3.4. Appropriateness of skill levels set by teachers compared to frequency of use
by practicing doctors

123
6.3.5. Priority of the selected skills as perceived by practicing doctors 125
6.3.6. Discrepancies between skill levels set by teachers and priority rating by
practicing doctors
125
6.3.7. Focus group discussions 127
6.4. Discussion 129
6.5. Conclusions 131

Chapter 7: Perceptions of graduating students from eight medical schools in
Vietnam on acquisition of key skills identified by teachers
135
7.1. Background 136
7.2. Methods 137


7.2.1. Study design 137
7.2.2. Study participants 138
7.2.3. Data collection tool 138
7.2.4. Data collection 139
7.2.5. Data analysis 140
7.3. Results 140
7.3.1. Students’ perception on whether they reached the level of skill listed in the
KAS book
140
7.3.2. Students’ perception of skill achievement 141
7.3.3. Study sites for learning skills 146
7.4. Discussion 148
7.5. Conclusion 151

Chapter 8: Community - University Partnership: Key elements for improving
field teaching in medical schools in Vietnam
155
8.1. Introduction 155
8.2. Methods 157
8.3. Results 158
8.3.1. Challenges for FT before intervention 158
8.3.2. Building a community-university partnership model 161
8.3.3. Main strategies and activities to improve FT in the eight schools. 163
8.3.4. Intervention activities for field teaching 165
8.3.5. Results after interventions 165
8.3.6. Evaluation of intervention by different stakeholders 168
8.4. Discussion 169
8.5. Conclusion 172

Chapter 9: Motivation of university and non-university stakeholders to
change medical education in Vietnam
179
9.1. Introduction 179
9.2. Methods 181
9.3. Results 182
9.3.1. Ministry representatives 184
9.3.2. Health service providers 185
9.3.3. Part-time teachers from hospitals and other institutions 185
9.3.4. Local FT preceptors 186



9.3.5. Community leaders and members 187
9.3.6. University stakeholders 188

9.4. Discussion 192
9.5. Conclusion 194

Chapter 10: Discussion and conclusions 197
10.1 Discussion 197
10.1.1. Medical education – why change it? 197
10.1.2. Medical education – change in which direction? 199
10.1.3. Research in medical education 206
10.2. Conclusions 208

Abbreviations 219
Summary 221
Samenvatting 225
Tóm tắt 229
Acknowledgements 234






List of Publications

Chapter 4: Hoat L N and Wright E P (2001). Constraints, challenges and lessons learned (In
TT. Bach and D. Burck (eds),
Implementing community-oriented teaching in
medical education - A case from Vietnam
(pp 77-88) KIT Health, Bulletin 348,
Amsterdam, ISBN: 90-6832-837-9.) (Reproduced with the permission of the
publisher.)

Chapter 5: Hoat L N, Yen N B, and Wright E P (2007). Participatory identification of learning
objectives in eight medical schools in Vietnam;
Medical Teacher.
29 683-690.
Chapter 6: Hoat L N, Dung D, V, and Wright E P (2007). Practicing doctors' perceptions on
new learning objectives for Vietnamese medical schools;
BMC. Medical
Education.
7 19.
Chapter 7: Hoat L N, Son N M, and Wright E P (2008). Perceptions of graduating students
from eight medical schools in Vietnam on acquisition of key skills identified by
teachers;
BMC. Medical Education.
8 5.
Chapter 8: Hoat LN, Wright EP: Community - University Partnership: Key elements for
improving field teaching in medical schools in Vietnam,
accepted for publication
in Rural and Remote Health
, September, 2008.
Chapter 9: Hoat, LN, Viet, NL, van der Wilt, J.E.W, Broerse, J., Ruitenberg, E.J. and Wright,
E.P. Motivation of university and non-university stakeholders to change medical
education in Vietnam
, submitted for publication
, October, 2008.

1
CHAPTER 1

INTRODUCTION
1.1. Aim and purpose of the thesis
Medical education systems must be able to train doctors with qualities that satisfy the needs
of society for medical care (Dowton & Brown, 2004; Lewkonia, 2001; Peabody, 1999,
Woollard, 2006). In consequence, when society changes, medical education has to change
as well (Boelen, 1999; Gibbons, 2006). To change medical education in relation to societal
needs is not a straightforward process. It demands commitment from the education and
health policy makers as well as from the medical universities themselves. To ensure that the
process responds to the needs of the society, involvement of stakeholders outside the
university is important, but often less convenient to organize and achieve. In this thesis,
the recent and successful process of change in medical education in Vietnam is dissected
and analyzed to provide evidence about how to develop a community-oriented medical
curriculum in eight medical schools in only a few years.
Vietnam has changed rapidly over the past two decades; economic development and an
open door policy have stimulated both economic growth and social change, and have
brought Vietnam into a different phase of epidemiological transition. The main diseases for
large segments of the population are no longer the diseases of poverty, but increasingly
diseases that are seen in wealthier societies (Ministry of Health, 2007). However,
development is unequally distributed around the country, and the gap between rich and
poor is increasing. While health problems related to a more prosperous lifestyle, such as
cardiovascular disease, diabetes and obesity, have started to appear more often among the
wealthier and usually urban segment of the population, those in both urban and rural poor
communities still commonly suffer from infectious diseases and malnutrition (World Bank
et
al
, 2001).
As social and policy changes brought about alterations in disease patterns and other health

issues, medical education in the medical schools of Vietnam also needed to change. Because
making the needed changes was beyond the financial and technical capacity of the
Vietnamese medical schools and ministries at that time, assistance was sought from external
sources and found from the Netherlands’ Government. The Dutch-supported project started
its first phase late in 1993, and continued with a second phase for a total of 12 years,
involving the eight main medical schools in Vietnam. The first phase included a situation and
organization analysis, resulting in the aim to integrate the topics of Primary Health Care and
Epidemiology in the curriculum of four medical schools. The second phase focused on
strengthening the community orientation of the curriculum and the quality of teaching in all
eight medical schools.
In the second phase, the systematic process of change started with better-defined learning
objectives, leading to a revised curriculum, appropriate teaching and learning materials and
methods, and student assessment tools. It was a long process that involved the
CHAPTER 1


2
participation of many institutions and contributors from within and outside the medical
schools. Stakeholder involvement during the process was very important for the success and
sustainability of the innovations supported by project interventions. Even with external
support, the project was a long and complex process that required moving and motivating
thousands of teaching staff in eight schools around the country, bridging not only
geographical distances, but also differences in ideas, experience and expectations. Because
of this complexity, a number of strategies and approaches were applied at different times, in
different situations, at different steps of the process.

In this thesis, the complex and complicated process of change in the eight medical schools
is described and dissected. The aim is to identify and to analyze the factors, actors and
conditions that influenced the achievements and failures of this project in its efforts to
change medical education in eight medical schools. The results and lessons learned from the
study provide evidence to support the Ministry of Health, the Ministry of Education and
Training and the medical schools in Vietnam to continue with the successes and to
overcome difficulties to continue the cycle of renovation in medical education. The results
are also made available for medical educationalists and scientists in other countries through
published books and articles as well as this thesis.
This chapter is the introduction to the thesis research. It includes a brief description of the
aims and purpose of the thesis, followed by the theoretical framework, presenting the
theories, models and approaches that were used to facilitate the changes in medical
education and to analyze the process of change, in the context of the project. Next it
describes the research design, mapping how the theories, models and approaches were
applied in the two phases of the project, chapter by chapter, and the publications related to
each set of results. The chapter finishes with an outline of this book.
1.2. Theoretical Background
The work described in this thesis grew from the context of medical education in Vietnam but
was strongly influenced by changes taking place in medical education around the world. As
described in the first section below, the past decades have seen a great deal of innovation
and experimentation in medical education, some of which was in response to social changes
in many countries. The analysis of the process of change in this thesis made use of a
number of models that were developed for management in the commercial sector but have
been fruitfully applied to education as well. The choices of models applied to help
understand the process of change in the Vietnamese medical schools are explained in the
second part of this section.
“Trying to change the teaching in medical schools is harder than trying to move
a mountain!”
Remark made by a teacher in one medical school during an evaluation survey.
INTRODUCTION

3
1.2.1. Medical education development
Education in general, from primary through secondary to university education, has been
undergoing a change in approaches to learning during the past few decades (Bush and
West-Burnham, 1994; McNeil
et al
2006, Guilbert, 2004). In Western countries this was
partly in response to other social changes taking place at the same time (Prideaux 2007).
Although those changes have not all necessarily been paralleled in Asia, many universities in
Asia have taken up the lessons learned from the experience in other countries and have
started to adapt their training programs as well (Amin
et al,
2005; Cheng, 1991). The focus
on the learning by the student instead of the teaching by the teacher has also profited from
the developments in technology and the increasing availability of information (Peer &
Martin, 2005; Prideaux 2007).
If the graduates of medical schools are to meet the needs of the health system even as
those needs change with the evolving economic and social situation, then the medical
curriculum should focus on the desired outcome (Dowton, 2005; Harden 2002; Harden
et
al
., 1999; McNeil
et al
, 2006; Wellbery, 2006). Outcome-based education is focused on the
capacity of the graduates, the products of the training process, more than on the training
process itself. This focus has been at the basis of many of the developments in medical
education during recent years (Harden
et al

, 1999a and 1999b). Focusing on the expected
capacity also demands reviewing and revising the process, including the curriculum contents
and the materials and methods used in the teaching. In several European countries, a set of
learning objectives based on expected outcomes was developed by groups of experts, to
guide the development of the curriculum and teaching in all medical schools in that country
(Metz
et al
, 1991, 2001; Rubin & Franco-Schwarz, 2002; Simpson
et al
, 2002). As Hays
(2007) described, graduates of different medical schools in different countries or even
regions within one country may be expected to have different capacities, related to the
demands of the local situation. There have also been attempts to develop a basic standard
curriculum that could be applied for medical education around the world (Core Committee,
2002; Schwartz & Wojtczak, 2002), with the idea that any doctor practicing anywhere would
need at least a basic set of competencies that could be defined by international agreement.
These attempts, however, have not yet resulted in a consensus about the minimum
requirements for medical education.
Innovation in medical schools has often been proposed to take advantage of an opportunity
such as establishment of a new medical school in a new region. For example, in Malaysian
medical schools, new approaches were seen in new medical schools, while existing schools
were slow to take up the innovations (Azila
et al
, 2006). The innovative curricula were first
developed according to professional expectations, while the movement towards community-
orientation and student-centered learning gradually made them more responsive to internal
and external factors that affected outcomes (Azila
et al
, 2006). In this process,
dissemination of information and involvement of teachers in decision-making were keys to

ensuring that they implemented the renovated teaching as planned (Azila, 2002).
Reform of medical education, like other change processes, is closely related to the existing
organizations and the power structures in each country and context. For example, Jippes
and Majoor (2008) recently compared the power structures in different countries and the
CHAPTER 1


4
success of introduction of problem-based learning among more than 100 medical schools in
Europe. It was clear that PBL was more successful where there was more openness to
innovation. In Vietnam, the process of change proceeded slowly and over several years,
using lessons learned from the experience of other countries as described in reports and
publications, as well as visits from experts and study visits. But the process and the changes
were adapted to fit the Vietnamese cultural context, in which the authority of the leaders is
still highly regarded, at least in the traditional organizations such as state enterprises and
universities (Nga, 2005; Quang & Vuong, 2002).
Changes in a university’s curriculum can be introduced either from the top – using the
authority of the leaders to require participation by the staff – or through involvement of
staff at all levels and other stakeholders – a more bottom-up approach (Prideaux, 2001;
Stratton
et al
, 2007). The top-down approach was more common in earlier decades, and the
bottom-up approach was introduced in the 80s. Currently a mixture of the two is considered
necessary, depending on the local situation and culture (Macdonald, 2003). The conflicting
demands between the need to steer curriculum development and the advantages of a
participatory approach require exploration of different strategies to find the balance that can
work in each situation. Stratton
et al
(2007) compared the management and monitoring of
the educational process to the production of a complex product, because the education of a

medical doctor also requires a series of processes that have to be structured, sequential and
measurable.
One feature of the complex process is the involvement of a wide range of stakeholders in
the process both of medical education and of medical education reform. To be successful,
the process should involve the different stakeholders within the school, including not only
the managers and decision-makers, but also teachers and students (Genn, 2001; McLean,
2003). Wahlkvist
et al
. (2006) were able to assess the effects of input from student
feedback and found that descriptive, open-ended feedback both initiated and validated long-
term development of the training.
The curriculum reform can take any of several directions, and hybrid or mixed approaches
are common. One feature that is increasingly common is increased orientation to the needs
of the community, which often involves a period of time for the students to work in the
community, in one of a variety of approaches. An early example of the community-oriented
approach was at the Christian Medical College in Vellore, India, where many inexpensive
strategies were developed to provide community experience for the students (Abraham &
Abraham, 1993). Many other schools followed with increasing community orientation,
especially – but not only – in developing countries (Mash and De Villiers, 1999; Mennin
et al
,
1996; Okasha, 1995; Sharma
et al
, 2007; Tamblyn
et al
, 2005). Wellbery (2006) reported
that although a medical curriculum should be patient-centered as well as student-centered,
in fact in many cases what was taught in the schools was not quite relevant enough for
what the students encountered during placements in real working situations.
Another feature of the reform can focus on the methods and related materials used in the

teaching. The range includes the classical lecture approach as well as a variety of more
active and interactive approaches, including problem- or scenario-based learning (Schmidt,
1993). Problem-based learning (PBL) was pioneered and is still used at McMaster University
INTRODUCTION


5
in Canada (Neufeld & Barrows, 1974); since then many medical schools around the world
have used it, often blended with other approaches (Wood, 2003). In this strategy, students
work together in small groups to collaborate on solving typical problems designed by the
teachers, and to reflect on their experiences. In PBL, learning is driven by presenting
students with challenging, open-ended problems that they solve by reading and discussing
in their groups. The role of the teacher becomes that of a facilitator, to support the learning
by the students. The main advantage of PBL is reported to be the development of
communication, problem-solving, and self-directed learning skills by the students, in
addition to a deeper learning of the content (Koh
et al
, 2008; Schmidt
et al
, 1987).
However, opinions about PBL and its effectiveness, compared to more traditional curricula,
are not uniformly positive, and most medical schools have not adopted a ‘full’ PBL but have
mixed it with other methods, including traditional lecturing (Gwee & Tan, 2001; Williams &
Lau, 2005).
The need to ensure enough opportunity for practice of skills has led to the development of
extra practical sessions using models and simulated patients in the ‘skills laboratories’
(Remmen
et al
, 2001). Especially in medical education, the opportunity for students to take
the first steps in using a skill on a model instead of a real patient brings benefits both to the

students and to the patients (Nielsen
et al
., 2003). Good use of the skills laboratory,
however, requires a detailed plan for what actually needs to be learned there, as part of the
overall learning objectives in the curriculum (Nikendei
et al
, 2005).
These experiences and results from many medical schools all over the world contributed a
wealth of information that helped in the choices made for the directions of change in
Vietnam. Many of them, however, were going on at more or less the same time in other
countries and in Vietnam, so that the lessons from other countries also often acted as
confirmation of appropriate choices, rather than examples to be copied. The achievements
of the curriculum change process in Vietnam were both a curriculum that is more
appropriate to the needs of the community-oriented medical doctor and a system in which
change can continue in a cycle of review and revision in response to changing needs.
1.2.2. Management of change
The literature provides a number of models to describe organizations and how they go
through a process of change. Usually they have been applied to commercial enterprises, but
examples of application to health systems and community development can also be found
(Greenhalgh
et al
2005; Ellis
et al
, 2005; Stratton
et al
, 2007). Stratton
et al
(2007) applied
them to analyze a hybrid quality-assurance governance structure in Kentucky; they used the
experience from industry to separate management from implementation of the process of

teaching the medical students. They also recommended a more management-oriented
approach to ensure the maintenance of curriculum quality.
In this thesis, the development of a more appropriate common medical curriculum and the
aim to improve medical education for the eight main medical schools in Vietnam is followed
and analyzed using different organizational models. Introducing new ways of working in the
universities is a process of change that can be compared to other change processes studied
by management researchers during the past decades. Most of the models and tools
CHAPTER 1


6
developed to follow changes and guide change processes have been developed for industry
and agriculture, but they can also be applied to education, including medical education
(Stratton
et al
, 2007; Sansom-Fisher & Lynagh, 2005).
Situation analysis
Change processes commonly start with an analysis of the present situation, and for that a
heuristic model is useful to identify which features should be considered for intervention.
Many models and tools for conducting a situation analysis can be found in the literature
(e.g. 56 are described in ten Have
et al
., 2003). Lusthaus and Adrien (1998) reviewed
management models that could be applied to management of organizations around the
world, finding weak points in many of them, and ended by developing their own model. This
model was applied to assess the performance of non-governmental organizations; it focused
on performance. However, it provides fewer opportunities to assess categories useful for the
universities than some other models do, particularly the Integrated Organization Model (see
below) and was not chosen for the analysis in this study.
Another potentially relevant model was the SOSTAC, developed for marketing

communications planning (Smith, 1990) that includes six basic elements for a Marketing
Plan:
Situation:
Where are we now?
Objectives:
Where do we want to get to?
Strategy:
How are we going to get there?
– The Big Picture
Tactics:
How are we going to get there?
– The Detail
Actions:
Who is going to do what and when?
Control:
How can we control, measure and develop the process?

This model is useful for assessment and planning in a project planning cycle; although
situation analysis is its first important step, the criteria to analyze the situation are not
provided, so the model was less useful for our purposes.
Some of these management models and concepts have also been applied to the
management of education (O’Neill, 1994). However, few of them seemed appropriate in the
context of both medical education and the culture in Vietnam. A selection was made of four
in particular that seemed to fit in the context of this study: the IOM, the Rogers’ Diffusion of
Innovation model, the Herzberg Theory of Motivation and the Johari Window. These models
and their application in this study are described in the following sections.
Integrated Organization Model (IOM)
is a comprehensive model that can include many
features of an organization (Boonman, 1999). It takes into consideration both external and
internal components, as well as their relationships to each other and to effectiveness,

legitimacy, efficiency, flexibility, continuity and suitability, all of which affect the changes
and interventions (see Figure 1-1).
This model was developed by Management for Development Foundation (MDF) in the
Netherlands and has been applied in their Institutional Development and Organizational
INTRODUCTION


7
Strengthening training courses to support change as part of development processes in all
kinds of organizations in many countries, including Vietnam
1
(see www.mdf.nl). The
external components in this model consist of mission, inputs, outputs, factors and actors.
Factors here appear in the general environment (economic, political, natural, socio-cultural,
technical factors) and actors are the specific entities in the environment (individuals or
organizations that play roles as providers, target groups, donors, supporters, competitors or
collaborators). The internal components are aspects inside an organization, such as
strategy, system, structure, management style, personnel and culture (see Figure 1-1).

Figure 1-1: The Integrated Organization Model according to MDF
* Source: Training materials distributed by MDF in IOM training course, Hanoi 2004

The IOM model has been widely used as a diagnostic tool to select intervention strategies,
to plan a process of change and to assess the results of implementation, based on an
understanding of the existing organization in its environment. As part of the IOM, standard
management tools, such as the environmental scan and the strengths, weaknesses,
opportunities and threats (SWOT) analysis (ten Have, 2003) are applied to analyze the
situation. This model was selected for the situation analysis for medical education in
Vietnam (details of the analysis are presented in Chapter 3).

1
/>strengthening?mod[MDFCourseCalendarModule][item]=65
Or
g
anization
Factors:
Economics, Science and Technology, Policy, Culture, Society
Actors:
Providers, donors, target groups, collaborators, competitors
Management
style
Staff motivation
Organizational
culture
Strategy
Hardware (visible)
Software

(invisible)

Mission
Outputs
Inputs
Structure
Systems
CHAPTER 1


8
Diffusion of innovation
Change is brought about by implementing interventions. As a result of interventions, change
can spread through the organization or members of a network either actively, through
planned dissemination activities, or more passively, by diffusion (Greenalgh
et al
, 2005).
Diffusion even without activities to promote dissemination will occur when the new ideas
have relevant characteristics that make them attractive to others in the organization or the
community (Denis
et al
, 2002). These characteristics are discussed below, with reference to
medical education in particular. In the project, activities were also organized to promote
diffusion of innovations that were introduced.
The concept of ‘innovation’ in processes comes from business and agriculture, where it is
defined simply as “s
omething new to the people to whom it is being introduced”
(Rogers,
2003). That means that an innovation that has been established for a long time in one context can

be new in another context and will have to undergo similar processes to become established
there. In the process of change in the Vietnamese medical schools, key innovations included
the process of reviewing and renewing the curriculum to identify the knowledge,
attitudes and skills (KAS) needed by medical graduates in Vietnam, necessarily
followed by new methods of teaching and the related appropriate teaching and
learning materials and assessment tools.
Studies in management and social science have shown that the process of introduction
and spreading of innovation through a system or organization follows similar dynamics
and show similar features, even in quite different organizations (Rogers, 2003).
The first point about innovation is that it has to start somewhere. It usually comes from
information acquired from new connections, insight gained from exploration of other
disciplines or visits to other places, or from active, collegial networks. But innovation can
only enter when at least one door is open. Innovation arises from exchange, when
information is not just accumulated or stored, but also created and shared (Wheatley,
1992). In some way, such connections act as a ‘trigger’ for innovation. The main triggers for
innovation may vary for different types of organizations with different cultures. To get
innovation started, it is important to find the appropriate triggers for the specific context.
The context of a medical school may differ in some ways from the context of a commercial
business or sports organization. For the Vietnamese medical schools, the type of culture is
most compatible with what Rogers called, ‘communal culture’ and the triggers he identified
for that culture (teamwork, participation) and its characteristics (strong leadership, longer-
term projects) are clearly related to the success of the process of change in Vietnamese
medical schools (Rogers, 2003).
Once the process of innovation has started, the challenge is to maintain interest and
support the gradual spreading of the innovation throughout the organization – in this case
the network of eight medical schools and the two related Ministries. The diffusion of
innovation model emphasizes that the diffusion and change process is often gradual
and that it depends on a number of key factors: (1) the characteristics of the
innovation itself, (2) the social system in which the innovation is introduced, (3) the
available channels of communication, and (4) the change agents who help to spread

INTRODUCTION


9
the new idea. Rogers used a curve in the shape of an ‘S’ to describe the process of
cumulative adoption of an innovation (Rogers, 2003). The curve represents the small
number of people who adopt the new approach early, followed over time by the majority
until the innovation becomes commonly accepted, and finally another small number who lag
behind in accepting the change (and may never accept it). Rogers also noted the existence
of a very important period in which a “critical mass” has to have accumulated before the
uptake curve can start to rise steeply (Figure 1-2).
This relatively simple representation of a complex reality helps to visualize the process and
therefore to influence it. Besides the rate of change, other factors influence adoption rates
(Rogers, 2003). For example, if another innovation is introduced when the adoption of the
first one is in mid-curve, then that could change the diffusion pattern of both in a significant
way. When the innovation involves networks, as for several processes in the innovation
pathway in the medical schools, they can interact and either reinforce or interfere with each
other and correspondingly increase or slow the rate of adoption of innovations. In the
Vietnamese context, the network factor tended to increase the rate of change in the
curriculum renovation process; the cultural emphasis on relationships and exchanges
(originating with the family networks) promoted network strengthening (Quang & Trung,
2005).

Figure 1-2: Shape of curve of diffusion for an innovation over a period of time,
showing the point at which critical mass is achieved
* Source: Adapted from Rogers, 2005

Change in an organization is brought about by the actions of the members, the people
working there. Rogers classified the people responsible for the adoption and diffusion of
change into five groups (Figure 1-3; Table 1-1).

Critical mass