Part II.
Successes and Failures

CRITICAL SUCCESS FACTORS

One of the goals of this report is to reveal some of the factors that appear to have made the Pew Health Policy Programs (PHPPs) a success. In so doing, it is hoped that the constraints as well as the lessons learned by the programs can be identified and ultimately that the legacy or legacies can be uncovered. It is hoped that incipient health policy and graduate programs can learn from these experiences and use this narrative to guide them through the process of planning, implementing, and developing innovative and effective programs.

This section focuses on what has been termed the critical success factors of PHPP, as a whole. Critical success factors are a ''limited number of areas in which results, if they are satisfactory, will ensure successful performance" (Rockhart, 1978). These factors, identified by the 25 interviewees, through discussions held at the Pew meetings, and by sifting through archival information, form the foundation of the Pew Health Policy Fellowship Program.4 These performance areas represent program activities that are interdependent, that work in unison to generate success, and that should therefore receive attention. They are (in no particular order) recruitment, mentoring, building a community of scholars, an early focus on the dissertation, networking, leadership, and multidisciplinary education and training. As a result of different service concepts, different operating strategies, and other variables, each program emphasizes different sets of success factors at different points in time.

RECRUITMENT

Kate Korman stated that "a variety of needs ... exist in the potential student population: postdoctoral, doctoral (both

4  

 Hal Luft noted that these factors are derived from people closely involved in the program and do not reflect the type of formal assessment one could derive from a study of many programs, some of which are successful and some of which are not.



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The Lessons and The Legacy of the Pew Health Policy Program Part II. Successes and Failures CRITICAL SUCCESS FACTORS One of the goals of this report is to reveal some of the factors that appear to have made the Pew Health Policy Programs (PHPPs) a success. In so doing, it is hoped that the constraints as well as the lessons learned by the programs can be identified and ultimately that the legacy or legacies can be uncovered. It is hoped that incipient health policy and graduate programs can learn from these experiences and use this narrative to guide them through the process of planning, implementing, and developing innovative and effective programs. This section focuses on what has been termed the critical success factors of PHPP, as a whole. Critical success factors are a ''limited number of areas in which results, if they are satisfactory, will ensure successful performance" (Rockhart, 1978). These factors, identified by the 25 interviewees, through discussions held at the Pew meetings, and by sifting through archival information, form the foundation of the Pew Health Policy Fellowship Program.4 These performance areas represent program activities that are interdependent, that work in unison to generate success, and that should therefore receive attention. They are (in no particular order) recruitment, mentoring, building a community of scholars, an early focus on the dissertation, networking, leadership, and multidisciplinary education and training. As a result of different service concepts, different operating strategies, and other variables, each program emphasizes different sets of success factors at different points in time. RECRUITMENT Kate Korman stated that "a variety of needs ... exist in the potential student population: postdoctoral, doctoral (both 4    Hal Luft noted that these factors are derived from people closely involved in the program and do not reflect the type of formal assessment one could derive from a study of many programs, some of which are successful and some of which are not.

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The Lessons and The Legacy of the Pew Health Policy Program Even though each program had a unique approach to health policy education and training, the four program sites worked together in team recruitment efforts, an their diversity enabled them to capture the best students from all levels and areas of health care and health policy. residential and nonresidential), and midcareer; and no one program can fulfill all these requirements." With this in mind, the Pew programs pioneered a joint recruitment effort, both implicitly and explicitly, to supplement their individual efforts. Understanding that each program had a unique approach to health policy education and training, those involved in recruitment from all four sites worked together to guide potential fellows toward the program that best met their individual needs and expectations. As a team, Steve Crane (Boston University (BU)/Brandeis University), Kate Korman (RAND/University of California at Los Angeles [UCLA]), Ted Benjamin (University of California at San Francisco [UCSF]), and David Perlman (University of Michigan) searched for potential recruits who would be appropriate and beneficial for the program as a whole and who would also fit well into a particular program site. Steve Crane and Kate Korman explained that students more interested in a traditional academic career were steered toward RAND/UCLA. People more business or problem oriented were directed toward the BU/Brandeis program. For those who could not or did not want to leave their careers or their homes for an extended period of time, the on-job/on-campus Michigan program was recommended. For students looking for postdoctoral education, UCSF was most appropriate, and for professionals without doctorates, seeking additional training in an intensive 1-year midcareer program, RAND/UCLA was suggested. "We all had something to contribute," says Steve Crane, "we were competitive only in that we all wanted to be seen to do well by Pew and to stand in the best light." The four program sites were related in that they all shared the same vision and mission. Their commonality enabled them to work together in team recruitment efforts, and their diversity enabled them to capture the best students from all levels and areas of health care and health policy. Profiles and Targets The 1994 Michigan Proposal Narrative states that a program "lives or dies by the quality of [the] student applications." Therefore, Michigan, like the other programs, engaged in major public outreach efforts. Targeted for the Michigan program were highly successful, often high-profile, midcareer professionals who were public sector representatives engaged in health policy formulation as either policy makers, policy analysts, or influential participants in the policy process, such as people in state legislatures and consulting

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The Lessons and The Legacy of the Pew Health Policy Program firms. However, Michigan learned early on that other vitally important aspects beyond professional position and influence are included in an applicant's profile. Leon Wyszewianski commented on the appropriate measures for recruiting fellows for the Michigan program and how this process changed over time: Brandeis wanted to participate in PHPP was so that the university could use the prestige and stipend to propel it into a more attractive position and recruit students of the highest quality. [Michigan] is an academic program. [It] is not another job. When all is said and done we offer pretty standard, straightforward doctoral-level courses. The students had to have the academic know-how to make it through these courses no matter what their other qualities were or accomplishments may be. We may have lost sight of that in the beginning. We tried to take in people who were very accomplished in the field but who were not necessarily great achievers in the academic realm. It was a disaster. They just couldn't cope with all this. If you're going to work full-time and go to school, you have to be very good at the "school" business. You have to already have mastered the craft of being a student.... We learned to pay a lot more attention to grades, past academic accomplishments, as well as GREs. We began to look for people who have shown that they can handle work and school at the same time. That is a good predictor of success. This was another lesson learned. no matter how applied this was, and even though we were not looking to create scholars, ultimately they can't take full advantage of what we have to offer if they are not good students. Program Champions The BU/Brandeis faculty and administration underscored Michigan's emphasis on the value of public communication and outreach in the recruitment process. Stan Wallack explained that one of the reasons that Brandeis wanted to participate in PHPP was so that the university could use the prestige and stipend to propel it into a more attractive position and recruit students of the highest quality. He conceded that although Brandeis was doing much state-of-the-art work in health policy that was being recognized and that was highly regarded, "students weren't just naturally coming to Brandeis." Stan Wallack stressed the need for active recruitment and the importance of having "program champions," people deeply committed to maintaining a high-quality student body: We found ourselves still needing to get out there and do a lot of recruitment....Steve Crane really took this program on as his mission. He was a key force....You need a champion. Steve Crane was a champion in terms of recruitment....The success of the program had a lot to do with Steve running this program, going out there, really identifying, working hard, writing to people, and going to the right kinds of meetings.

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The Lessons and The Legacy of the Pew Health Policy Program Joan DaVanzo stated that having a "point person" functioning inside the program with the fellows was also critical to the success of the fellows and the program. At RAND/UCLA Kate Korman functioned as the program champion. According to DaVanzo: Kate Korman was very nurturing and supportive of up—it was like a little family, with her as the "mother hen." She looked after us, made sure we all knew what was going on.... She made us feel connected to the institution and "on the inside," even though we were just these new, somewhat wet-behind-the-ears fellows. A "point person" functioning inside the program with the fellows is critical to the success of the fellows and the program. Joan DaVanzo discussed the difficulty of uprooting one's life to go back to school full-time, and in some cases even switch fields completely. Kate Korman made this potentially rocky midcareer transition smoother for the Pew fellows. Furthermore, DaVanzo indicated that Marion Ein Lewin, director of the Program Office, and her staff were always responsive to and supportive of the Pew fellows. Together, these experiences fostered a defined identity for the fellows and the Pew program. At BU/Brandeis, the doctoral applicant pool almost always included people who had been thinking about the need for more systematic and rigorous training in health policy analysis as a result of their professional activities (Richardson, 1990). Stuart Altman commented on Brandeis' recruitment goals: We were trying to recruit, and we did recruit, people who had worked for governments either at the state or federal level, but who had started out without a lot of formal training and needed a deeper understanding. We did attract a number of individuals who had been working in the health policy arena at the government level, but who had come in as pretty junior people. We added a conceptual framework to what they were doing. Then they reinserted themselves back into the policy process, often at higher levels. Proven academic ability and independent, organizational skills were major determinants for admission to the BU/Brandeis Pew program because of its accelerated nature. Steve Crane explained that recruiting for fast-track programs is different than recruiting for traditional graduate-level programs, and this difference must be taken into consideration: We wanted to create a doctoral program that would get you in and out within 2 years through a challenging process. We wanted to give students a great degree of flexibility in the courses they chose so that they would waste the least amount of time taking

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The Lessons and The Legacy of the Pew Health Policy Program courses that someone thought were important but weren't directly relevant. We wanted to take in students who already had an advanced degree and substantial experience and didn't have to learn what they wanted to do with their lives. We tried to identify and choose people who knew exactly what they wanted to do, and who could find what they were looking for here at BU and in that way get them in and out very quickly. Recruiting for fast-track programs is different than recruiting for traditional graduate-level programs, and this difference must be taken into consideration. Although this type of program is not made for everyone, Stan Wallack stated that for many fellows, the fast-paced curriculum was the primary attraction, and thus an effective recruitment tool: There are people out there who, when we first started the program, were ideally suited, who were seasoned people, who were out there in the real world a long time, and who didn't want to spend a lot of time in graduate school....They just wanted to pick up some tools. The 2-year program was appealing to some students, even if they struggled a little when they got here....We expected them to be done with their course work in 2 years and have a dissertation subject and be pretty well along when they leave. They could be expected to finish their dissertation within the third year. We wanted to make it a very fast-paced program that would distinguish us. Finding the Best and Brightest The postdoctoral PHPP at UCSF emphasized the importance of recruiting the very best among the highly qualified pool of potential applicants. The collective mission of the Pew programs is to train the future leaders of the health policy field; therefore, only the best and most promising applicants are selected. According to Carroll Estes, to achieve this level of applicants, the institution and faculty must also represent the best: ''The excellence of our faculty and their reputations were the single most important attraction in recruitment....You need a sterling faculty and a sterling institution for recruitment." The UCSF program typically enrolled five postdoctoral fellows each year, drawing on a very high quality national pool of applicants. Each year, there was a mix of medical and nonmedical doctorates, with the physicians drawn from preventive medicine and primary care specialties and the PhDs typically drawn from largely social science backgrounds. Placing fellows on research projects with the faculty is the most important aspect. "Identifying a good match is one of the key things that needs to be done," says Hal Luft. The process of identification begins during recruitment and entails not only matching people to the project with regard to energy levels and similarities of interests but also finding

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The Lessons and The Legacy of the Pew Health Policy Program someone who fits well into the program and who will fit well with the faculty and in ongoing projects. Like UCSF, the RAND/UCLA program incorporated hands-on research projects into the curriculum; thus, the importance of matching student profiles with faculty research projects and interests was an essential part of its recruitment process as well. Al Williams discussed the interrelatedness of targeting recruitment to the highest-quality students and of creating a thriving, high-quality program, since you cannot do either one well without mastering the other: [F]rom the beginning we tried to [skim the] cream. We intentionally made it a rich program because we wanted to get the best students....We were looking for people who had already done work that required, in the case of the PhD students, their commitment to health and in the case of the midcareer folks, we basically took in people that had convinced us that they were committed....[Most] had demonstrated substantial capability in a domain other than policy. Without Pew funds, "skimming the cream" would not have been possible. However, Al Williams noted that without Pew funds, "skimming the cream" would not have been possible and laments that today RAND is unable to recruit health policy fellows in the same way. Another factor that enabled RAND/UCLA to succeed in attracting high-quality students was the relationship between the two institutions and the availability of cross-registration. He provided the example that although the RAND Graduate School did not teach epidemiology, fellows had access to multitude epidemiology courses at UCLA. Thus, many students were going back and forth between RAND and UCLA, an opportunity that allowed for the development of a rich and comprehensive program. The joining of forces between BU and Brandeis also allowed for these cross-registration and program enrichment opportunities. Steve Crane expressed the commonly held belief that one of the great strengths of the program as a whole was the individual faculty members who were committed to Pew's mission and who were accessible to the fellows: Can you imagine sitting down in a room with Phil Lee, Stu Altman, Stan Wallack, Dick Egdahl, Al Williams, Bob Brook, and ... I could go on and list dozens of names ... and be able to go up to them and talk with them and think and discuss for a day or two [at the conferences] and then go back to your institutions and do that on an ongoing basis or if you want call someone up in another institution? Phil Lee, Assistant Secretary of Health; Stu Altman, Chairman of ProPAC [Prospective Payment Assessment Commission]; Joe Newhouse at Harvard, to speak with the people who are writing the articles, who are changing the world? Incredible. It was just incredible....The Pew HPP

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The Lessons and The Legacy of the Pew Health Policy Program was just unbelievably rich, and the commitment that the senior people had to this group of students was just extraordinary. That is something that can be replicated by another program. There is still a strong need to get people from different institutions together. That phrase "inter" is really so important. Not "intra," as doctoral programs traditionally are. They only look within themselves. This was "inter" in every respect of the word. Marion Ein Lewin has the unique perspective of having been the overseer of PHPP as a whole and having been closely involved in the evolution of each program. From her perspective, there have been tremendous improvements in terms of the recruitment process. Over time, the targeted market changed from highly intelligent people vying for a predoctoral, postdoctoral, or midcareer program to highly intelligent people with the same wants in terms of getting a degree or higher-level training, but who also had unique motivation, discipline, and organizational skills. The task imposed upon the Pew fellows was exceedingly demanding not only because of the complexity and unstable health care environment (the basis of the curriculum) but also because of the fast-paced nature of the program. In her words: The schools learned to recruit people who had the initiative and the discipline and the interest to pursue this kind of program, and who had what it would take to be a successful Pew fellow once they completed the program. My feeling is that the recruitment really was very much improved to ensure the success of the alumni. Over time, the targeted market changed from highly intelligent people vying for a predoctoral, postdoctoral, or midcareer program to highly intelligent people with the same wants in terms of getting a degree or higher-level training, but who also had unique motivation, discipline, and organizational skills. Jonathan Howland agrees with Lewin's conclusion that the recruitment process needs to include screening for motivation, but he adds the dimension of screening for completion. He stated that with regard to the doctoral programs, it should be made clear from the start that there is an expectation that comes along with being accepted into the program and that is, that the fellow will complete the program. This topic will be revisited later in the report. Hal Luft discussed some unique recruitment issues that come up in postdoctoral-level programs. People applying for postdoctoral fellowships are often applying for tenure-track positions simultaneously. Thus, if the postdoctoral application process ends before most institutions notify their new faculty recruits, the fellowship may lose some of the very best because they will be holding out to hear about faculty positions. This may seem like a simple logistical matter; however, competing external factors like this could have long-term effects on the quality of the student body and must therefore be addressed.

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The Lessons and The Legacy of the Pew Health Policy Program This section has elaborated mostly on the comments of the program directors, those with firsthand knowledge of the recruitment process. However, Dan Rubin noted that it would be interesting to look at how the fellows actually came to choose a particular program or even how they came to be interested in seeking the kinds of degrees and programs offered by PHPP. Although this was not one of the questions specifically asked of the alumni who were interviewed, the information gathered showed a clear consensus that going back for more rigorous training in health policy was the best way that the fellows imagined that they could either empower themselves in their current positions or have greater influence on policy making and change in the future. MENTORING During an advisory meeting in 1993, Phil Lee stated, "A good fellow-mentor relationship is one of the single most important determinants of a successful health policy fellowship." The importance of mentoring was clearly understood by all the programs, as evidenced by their emphasis on supplementing the classroom experience with various research projects that stimulated faculty and fellow interaction and that taught students how to apply theories and techniques to answer real-life problems. A good follow-mentor relationship is one of the single most important determinants of a successful health policy fellowship. The Institute of Health Policy, a leading health care and research center at Brandeis University, expanded its mission to include educational training. This enabled the Pew fellows to have access to key faculty and research staff. All research professors from the institute were held responsible for teaching and mentoring students. The Heller School and the institute firmly believed that a program in health policy would fall short if it relied only on traditional academics to teach policy research and analysis, so research practitioners were integrated into the core faculty (Raskin et al., 1992). Access to Key People The fellows from the BU/Brandeis program spoke highly of the mentorship offered by faculty at both BU and Brandeis. Many stated that because of their rich experiences and strong relationships with the faculty, they were not only inspired to provide but also felt appropriately prepared to provide similar mentoring to other colleagues and to their students. Fostering these kinds of relationships between faculty and fellows and between fellows and other fellows, where people

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The Lessons and The Legacy of the Pew Health Policy Program are comfortable and even eager to ask questions, give answers, probe issues, and challenge each other, is exactly what the Pew program was hoping to accomplish. These people trained by PHPP to respect, listen to, and learn from peers and colleagues will inform the debate and stimulate effective change. Linda Simoni-Wastila reflected on her experiences in the BU/Brandeis program: [O]n a personal level, I felt nurtured through the program by the staff and faculty, particularly Steve Crane, even though he was at BU; we had a joint program then. He was a real "mentor." I also got some good mentoring here, and the way we nurtured each other ... and sort of developed a need to mentor other people....Now I find myself in a mentoring position for students and even for some colleagues and I am prepared. The Pew program sort of facilitated that....Key faculty were available and eager to mentor the Pews. We had ready access. A Hands-on Approach For many follows the most important reason for participating in the program was the opportunity to participate in multidisciplinary health policy and health services research with the faculty of the institutes. Although the seminars and course work are vital parts of the UCSF Pew Health Policy Program, for many fellows the most important reason for participating in the program was the opportunity to participate in multidisciplinary health policy and health services research with the faculty of the institutes. This environment is further enriched by faculty-fellow interaction and the mentoring that faculty provide (Lessons Learned, UCSF, 1992–1993). The issues of faculty-fellow interaction and the mentoring and research training overlap to a great extent. Fellows receive detailed orientation to the faculty and their projects. Intensive, individualized programs of counseling, mentoring, and career development have been implemented. Carroll Estes cites the colleagueship and mentoring stimulated through large-scale projects as one of the most innovative methods of program implementation at UCSF. Hal Luft underscored his colleague's emphasis on the value of mentoring: The model that we chose worked well, and that's a model where the fellows basically get involved with one or two faculty members and work on some projects and get that bands-on experience. It's more of an apprenticeship model than a classroom model. Likewise, says Carroll Estes, "The fact that the two institutes at UCSF together have about $20 million in funded research every year and probably 40 faculty investigators who are well known in their area has really contributed to implementing very significant training opportunities."

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The Lessons and The Legacy of the Pew Health Policy Program The postdoctoral fellows at UCSF had close contact with their assigned advisers and met with them regularly to review progress in research, field placements, publications, course work, and career planning. Faculty monitor and evaluate each fellow's progress, adjust his or her individualized program according to emerging needs, and provide assistance with specific problems. Regular meetings provide an opportunity for informal discussions and for forming the kind of trainee-mentor relationship that is so vital for career development (Lessons Learned, UCSF, 1992–1993). Faculty usually found that the benefits of working with a fellow far exceeded the time of mentoring, provided that the match was a good one in terms of skills, content, timing, and expectations. In an effort to improve faculty-fellow interaction, all UCSF Pew fellows received guidelines listing the expected goals of the Pew fellow-mentor arrangements. This helped them to know what was expected of them and what they could expect from their faculty preceptor. Fellows and faculty were also provided with general guidelines for establishing a productive and enjoyable relationship with a mentor. These simple guidelines helped to clarify the confusion that often surrounds the roles and responsibilities expected of fellows and faculty in academic programs. (See Appendix C for guidelines.) Pew funding permitted students to offer free assistance to a faculty member in exchange for ongoing mentoring and inclusion in a research project that would meet the individual fellow's training goals. Faculty usually found that the benefits of working with a fellow far exceeded the time of mentoring, provided that the match was a good one in terms of skills, content, timing, and expectations. It was made clear that fellows were "free agents" in their dealings with faculty mentors, and if things were not working out, they were free to seek out another faculty member and research setting. In the experience at UCSF, changing mentors because of irreconcilable conflicts over the research approach was rare, but conflicts over authorship occasionally occurred. This led to encouraging faculty and fellows to discuss issues of authorship order at the beginning of a writing effort. When asked how the UCSF postdoctoral fellowship approach differed from a traditional postdoctoral fellowship, Carroll Estes responded: This is much more of an interdisciplinary experience and much less of a lone wolf researcher, do it independently on your own and sink or swim on your own. There is much more of a faculty-planned approach and commitment, with annual reviews, mentorship meetings, preceptor meetings, scheduled reviews of students, and group meetings with faculty members on programs of activity in what they've accomplished and what they want to accomplish and getting mentorship and advice on

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The Lessons and The Legacy of the Pew Health Policy Program papers, research proposals, and jobs. I don't think in most other fellowships there exists this kind of tutelage. There is a real community commitment here. Estes attributes the success of the mentorship program to the general support provided by the Pew program for faculty who would not have support for any teaching or mentorship concerns otherwise. Research collaboration between fellows and faculty does not end at the conclusion of the fellowship period. Fellows who assume academic positions, in particular, are often involved in completing research and publications initiated during the fellowship as well as developing research proposals out of earlier projects. The extent to which postdoctoral fellows who have graduated continue to collaborate with faculty from their programs may be one way to measure the success of the mentorship available during the training period. For example, Joan DaVanzo, who went through a combined doctoral program at RAND and UCLA, emphasized the value of the work projects in fostering close mentoring relationships. In addition to getting on-the-job, real-world experience, the work projects allowed for close contact with the faculty and project directors. Specific steps were taken at all sites to foster a feeling of community among the Pew follows. The University at Michigan program is designed to provide active support for doctoral fellows for a 3-year period. There are 2 years of course work and additional support for the completion of the dissertation. The demands of course work and dissertation projects are substantial, competing with full-time professional activities. To deal with this obstacle, faculty began to closely monitor and provide increased academic and psychological support to the fellows. According to Richardson (1990), this approach has been extremely helpful in assisting students in completing of their course work and dissertations. COMMUNITY OF SCHOLARS The fellowship is a transition period, with marked uncertainties about the future and a groping for identity as health policy researchers (Lessons Learned, UCSF, 1992–1993). In addition, fellows are often at similar stages in their nonprofessional lives, and the sharing of experiences is important. Therefore, specific steps were taken at all sites to foster a feeling of community among the Pew fellows through traditional and formal methods such as seminar-style classes, lunchtime colloquia, and conferences. However, PHPP helped to create a sense of community through other, less

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The Lessons and The Legacy of the Pew Health Policy Program are nationally oriented, cutting across all political boundaries. There continues to be a dire need in the health policy community for people who can see the big picture and apply that vision in an effective way, the way that the Pew fellows were trained to do: A lot of programs produced people just for the public sector, or just for the academic sector, but rarely just for the private sector. What we wanted to do [at BU] was to have someone who had not only the vocabulary, but the knowledge to cross-walk academics, public service, private sector and not-for-profit.... I think [this] need still exists and most of the academic programs are still turning out discipline-focused individuals. Brandeis-Heller is an exception. What we need are people who can understand problems from a multiplicity of viewpoints, who can create solutions that cut across disciplinary and sector perspectives. We are still short on people who can do that. Stan Wallack discussed the importance of training students to look through the various "lenses" of health policy. He explained how the Brandeis curriculum was multidimensional in terms of political science, economics, and sociology and how a specialization in health was built in using the lenses of the economist, the political scientist, and the sociologist. Stan stated that it is essential for these different paradigms and other perspectives to be incorporated in any program teaching health policy. Despite the importance of multidisciplinary education and training for policy research, policy making, and change, the integration of different disciplines and experiences into advanced graduate training is still quite rare. Nonetheless, Dan Rubin from Michigan hopes that the prestige of the schools and the success of the programs will ultimately work to disseminate the interdisciplinary training approach at the doctoral and postdoctoral levels. Kathleen Eyre stated that it was this aspect of the curriculum—the integration of the different social sciences into a health policy framework—that distinguished the Pew approach training from the traditional training approaches. Hal Luft explained that the innovative training approach used by PHPP enabled the fellows, once they entered the field, to continue interacting and communicating with professionals from other disciplines in their own or other sectors. Communication of this nature is fostered during the training years when the academically focused and nonacademically focused fellows merge their expertise to work on projects and solve problems. As a result of this training approach, explains Hal Luft, fellows who go on to

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The Lessons and The Legacy of the Pew Health Policy Program become policy analysts in the government can call upon their colleagues in academia for advice in ways that would not have been possible had they not gone through joint training. Al Williams underscored the value in exposing fellows to projects where they would have to work together with professionals with expertise in various areas. This kind of preparation significantly affects the future success of the fellows. The general consensus was that the health policy field needed broadly trained health policy professionals to effect change. PHPP prepared its fellows for this challenge. In reference to the doctoral program in particular, Dennis Beatrice stated that through this innovative multidisciplinary training approach, ''Pew educated a new kind of PhD, one better prepared and more relevant for today's world." LEADERSHIP ROLES Pew educated a new kind of PhD, one better prepared and more relevant for today's world. It is interesting and noteworthy that IOM had an interest in the Pew Health Policy Program from the start. Marion Ein Lewin remembers that when the Pew Charitable Trusts began looking for an organization to direct the program, IOM had responded but had not won the proposal. The Pew Health Policy Program was brought to IOM from the American Enterprise Institute in 1987; however, it was not officially called the Program Office until 1988. It was on the recommendation of Bill Richardson, who conducted the program evaluations, that IOM was named the official Program Office. Role of IOM Marion Ein Lewin describes the role of the IOM office as one that develops the joint activities of all the programs, plans annual meetings and meetings for new fellows, develops the directory and semiannual newsletters, monitors the budgets, and makes sure that all the programs are performing according to the requirements of the program. Perhaps most importantly, IOM is responsible for the network and the "family" of Pew fellows over and above their connection to the individual programs and institutions. The success of this aspect of the IOM Program Office's responsibility can perhaps be best described by a quote from Jonathan How-land, a BU/Brandeis Pew alumnus who also had the unique experience of directing the Pew program at BU for a time. The Pew fellow's identity was so transcendent and we all felt like Pew fellows, and that had a higher profile than what school we were at.

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The Lessons and The Legacy of the Pew Health Policy Program Creating a Vision for a National Training Program The definition of "success" varies across graduate programs. Traditionally, successful doctoral or postdoctoral programs would seed the academic field with their graduates, and successful midcareer programs would seed the management field. PHPP however, aimed to seed the whole field of health policy, encompassing the academic world, the health care management world, the various levels of government, the corporate world, and the public and private sectors. How can one program, however, produce successfully trained health policy professionals to meet the needs of so many different areas of the health care field? One way is for each program to establish a strong multidisciplinary core, a sense of urgency, and a national identity that rises above all of the programs and the fellows' individual aspirations and career paths. A Transcendent Pew Identity The leadership of PHPP was able to foster this sense of belonging through an empowering Pew identity, but it was not easy. IOM and the program administration went to great lengths to instill in the Pew fellows a sense that they were all, regardless of their backgrounds and expertise, working toward a common goal, that is, to be more effective change agents in the health policy arena. Marion Ein Lewin reflected on the painstaking but enormously rewarding process. She stated that in the beginning none of the students thought of themselves as "Pew fellows"; rather, they looked at themselves as individuals all getting degrees or going through training programs at individual sites across the country and that Pew was only a financier. During the first year or two, the fellows thought that the source of program funding was the only common bond between their programs. As Marion Ein Lewin stated: At that time there were a lot of fellows who were community activists and who wanted to be change agents but in a way that said, we have our values, we have our agenda, we know what we want to accomplish, and we don't care what the rest of the world says, we don't have to communicate with the rest of the world. I remember that I felt that we [the program directors] really had our job cut out for us. If you're going to be a change agent I think the first lesson is that you have to be able to dialogue with the people who art in power even if you disagree with them. If you're just going to wall yourself up as the strong opposition, you're not going to understand where these people are coming from and you're never going to be an effective change agent.

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The Lessons and The Legacy of the Pew Health Policy Program In an effort to counteract this early hostility, the program administration incorporated controversial presentations into the Houston national meeting in 1989, and tried to teach the fellows how to communicate effectively with people who have varying perspectives. Marion Ein Lewin describes what happened: Some of the fellows didn't like some of the panelists because they didn't care for their views.... Leon Wyszewianski from the Michigan program got up and said that the purpose of being a Pew fellow is that you gain an understanding about how to be effective change agents in the world of health policy and the purpose of the Pew Health Policy Fellowship Program is for people to become good communicators and to work in the real world, not in some ideological world. Marion Ein Lewin explained that this was a real turning point for the program because it was the first time that there was a discussion about what it meant to be a Pew fellow, that it was something above and beyond just financing an education. The fellows began to learn that the program had a purpose and that it wanted to create a cadre of similarly trained people who could work effectively in health policy at all levels and in all sectors. The fellows began to learn that the program had a purpose and that it wanted to create a cadre of similarly trained people who could work effectively in health policy at all levels and in all sectors. Many others claimed that the program office helped the individual academic programs to achieve their goals. The goals of program leadership extend beyond integration and the fostering of community. They included motivating fellows to complete their challenging and difficult programs. Joan DaVanzo discussed how the dedicated leadership of the program sites and IOM set the PHPPs apart from other doctoral programs: Doctoral programs are usually very hard to finish, and there are a whole bunch of ABDs around. At RAND/UCLA the motivation to finish was very strong. The Pew programs created a real strong motivation to finish, and they did that in a variety of ways. Some of it being networking with alumni and seeing these people in these neat jobs and writing these great papers and you wanted to finish and join them.... A lot of the motivation is created by the program. Likewise, Linda Simoni-Wastila discussed how the leadership motivated her to finish her doctoral program at Brandeis: The support of people like Marion Lewin motivated me to want to finish and contribute to the field.... My experience with Pew continues to motivate me. When I get the Pew newsletter and I see where everyone is and what they are doing, I think wow, that's great. It makes me want to go out there and publish more and contribute more and do more. In that way Pew has touched me professionally. It has made me more enthusiastic about what I do, not that I wasn't before, but it has given me that extra boost.

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The Lessons and The Legacy of the Pew Health Policy Program Following along the same idea articulated by both DaVanzo and Simoni-Wastila, Jonathan Howland discussed how the program leadership distinguished PHPP from other traditional doctoral programs: In other doctoral programs there is more of an adversarial relationship between the doctoral candidate and the faculty. You may have your mentor, but as a whole, the department's view is that you have to prove that you are worthy of our bestowing this doctorate from our department. There is this kind of onus on the individuals to prove themselves. In the Pew program, the faculty had a real stake in getting people through, and high attrition rates were not a good thing.... Faculty were stakeholders in the success of the program.... Every failure is a failure of the program. Howland explained that there are two sides to this leadership approach, one positive and one an area for concern. On the positive side, the fellows had access to a "very user-friendly faculty" who believed that there was value in appropriately training fellows and allowing them expeditious entry into the field. On the less positive side, this approach allowed some fellows to be irresponsible in terms of course selection, the amount of work that they did and what learning they did. Nonetheless, overall, the fellows were mature enough to take on the challenge of a nontraditional, accelerated program, and the supportive environment succeeded in producing effective health policy professionals focused on real-world issues. Role of the Trusts Overall, the fellows were mature enough to take on the challenge of a nontraditional, accelerated program, and the supportive environment succeeded in producing effective health policy professionals focused on real-world issues. The Pew Charitable Trusts were also commended for their strong commitment to leading and administering the Pew Health Policy Program. According to Marion Ein Lewin, the Trusts' faith in the program never wavered. She explains that the directors at the Trusts had an uphill battle because foundations do not inherently like to fund programs for the long term. From the beginning, the willingness on the part of the Trusts was crucial to the success of the program. Steve Crane reiterated the uniqueness of Pew's commitment: The Trusts have been very supportive. They are our colleagues in all of this. They hung with us when things were rough. They celebrated our victories. The Pew Trusts deserve a lot of commendation for doing this and sticking with it. There are as many lessons to be learned on their side about how you deal with fellowship programs. If this model is to be replicated, what the foundations are going to need to know about is not only how it works at our end but how it works at their end.

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The Lessons and The Legacy of the Pew Health Policy Program THE "PRICE" OF INSTITUTIONALIZATION-FINANCING ISSUES The Pew Charitable Trusts' decision to discontinue financial support for the health policy programs with the final grant in 1991 was based on the premise that over the 15 years of funding, three very distinct and highly successful models had been developed, and these models should become institutionalized and adopted by other institutions (Pew Charitable Trusts, Rimel and Asbury, 1995). The Trusts' claim that the last grant was, in part, a transitional effort to enable the sites to develop "how to" materials and to explore alternative approaches to financing their programs in the future. The Trusts, however, recognize that with potential reductions in health services and policy research funding these models may be difficult to sustain in the future. University of Michigan The Trusts recognize that with potential reductions in health services and policy research funding these models may be difficult to sustain in the future. In 1993, the Michigan Pew Program Advisory Committee assessed the feasibility of continuing the Michigan program if and when the Pew funding was discontinued. They determined that the university would probably not be able to retain the many faculty members supported by Pew money. They were also concerned that only those students who could afford to self-fund their education would apply to and enroll in the program. They hypothesized that such a situation might lead to a more homogeneous cohort of students, a loss of diversity in backgrounds and perspectives, a more regional student body, and a loss of national focus. The advisory committee feared that the university would be faced with the decision to retain a program of greatly reduced quality and scope or to end the program completely. This was of grave concern because the Michigan program is still the only nonresidential (on job/on campus) doctoral program in the United States. Ending the program would clearly leave a devastating void (Site Visit, 1993). The Pew doctoral program at the University of Michigan selects midcareer professionals who are active in policy formulation and upgrades their knowledge and skills, thus enabling them to participate more effectively in the policy process. Approximately two-thirds of these individuals receive salaries that make the costs of tuition, fees, travel, and books for the program unaffordable without assistance. Patricia Butler commented on the problems of sustaining a midcareer nonresidential program like the Michigan program without funding and the changes that reduced funding would likely bring:

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The Lessons and The Legacy of the Pew Health Policy Program Most of us were midcareer and many of us live in places where there isn't even a graduate level health policy program offered ... that's why I am so grateful to the Pew Charitable Trusts for supporting this kind of program. I am disappointed and concerned about what happens when the money goes away, as it has basically begun to do. I think it's a unique and extraordinary opportunity and one that I think should be available to others in the future. I am particularly concerned that as Michigan tries to make its program self-supporting, as they need to do without an outside source of revenue, then they're going to get mostly people who have deep-pocket employers who can send them and that will tend to be more people in the private sector, more health services administrators as opposed to health policy folks from public agencies ... more residents of Michigan who don't have to pay the out-of-state tuition. I think it's fine that Michigan gets to take advantage of this thing, but it was such a unique national resource that I am sorry to see the dollars go away. Pew funds have also enabled the University of Michigan to support visiting faculty. The program coordinators have found that students benefit greatly from lectures by specialists on important topics not necessarily on the research agenda of the University of Michigan faculty. The experience has also been enriched by faculty brought in from other institutions to develop courses or to fill in for local faculty who are unavailable to teach a necessary course (Michigan Proposal Narrative, August 1994). This flexibility in program offerings is very important in maintaining the quality of the Pew experience; however, it is in jeopardy as funding ceases. On a more positive note, the faculty and program directors at the University of Michigan are committed to sustaining the nonresidential doctoral program on their campus. Their primary concern, as highlighted previously, is maintaining the rich diversity that makes their program so valuable to the health policy field. Bill Weissert commented: There is no question that the [Michigan] program will continue. We have expanded it and bought off on it and found we can sustain it. The big problem is that we will not have funding and therefore we'll have a limited ability to reach people who need to be here with fellowships. We just don't have the money. To the extent that you're trying to reach people in the policy process, [it] is pretty important because it's a field where people are not particularly well paid. Thus, without the proper funding, we reduce our likelihood of influencing the policy process. But we will continue to get people who are either able to afford the program because they are MDs or who are supported by their organization or interest group. University of California, San Francisco The 1990 Hamilton evaluation states, "In all cases, the acid test of legitimization at the grantee institution itself is

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The Lessons and The Legacy of the Pew Health Policy Program whether the activities survive after the PCT [Pew Charitable Trusts] umbilical is cut.'' Indeed, all the Pew program sites have passed the test. At UCSF, the support for infrastructure and related training and research resources earlier in the history of the program were instrumental in acquiring permanent university funding for the Institute for Health and Aging. Hal Luft reflected on the structures now in place at UCSF as a result of the Pew program and the indirect benefits that PHPP has brought to UCSF. I suspect at UCSF that we would not have had a postdoctoral program had there not been the Pew funds to get it started. We would not have had the AHCPR [Agency for Health Care Policy and Research] training grant because that built on our experiences with Pew. And, I suspect that there would not have been as nearly as strong an application from Berkeley and UCSF for the Robert Wood Johnson Health Policy Scholars. I suspect the same thing would have been true at Michigan. All these things can be linked back to the Pew program. The Health Policy Management Program at UCSF that was funded during the first cycle by Pew was continued on a permanent basis with funds supplied by the UCSF hospitals and clinics to support one to two fellows a year (Richardson, 1990). Other efforts to institutionalize the Pew program have continued. At an advisory board meeting in 1993, Phil Lee and Carroll Estes reported that the seminars that were developed for the Pew program have been institutionalized at the Institute for Health Policy Studies. A major objective of the UCSF Pew postdoctoral program has been to develop the capacity to provide full financial support for core faculty and staff. However, this has been extremely difficult. Prolonged economic recession in California continues, as does an even more prolonged crisis in funding the state of California budget. Due to substantial cuts in state funding, the University of California as a whole, including UCSF, is undertaking major reductions in its workforce and salaries. In this climate of spending reductions, the university is loathe to take on additional responsibilities for new administrative or faculty expenses. Given the structural economic and government funding problems, there is little prospect in the foreseeable future for a substantial reversal in UCSF policy. At the same time, none of the other fellowship funding agencies fully pays for the real expenses incurred for core fellowship program faculty and staff. Most of these agencies appear to assume that they are involved with a normal university disciplinary department, with faculty paid for through

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The Lessons and The Legacy of the Pew Health Policy Program the university's annual budget, rather than two research institutes that depend almost exclusively on external sources of funding. The institutes do not have the financial resources to engage in cross-subsidization of the fellowship program activities for any significant period of time, since virtually all reserve comes from research contracts and grants, and discretionary funds are very limited. Thus, UCSF finds itself in the paradoxical position of training an increasing number of exceptionally qualified fellows while receiving a declining amount of support for core faculty and staff. Although the institutes will look to other foundations for financial support for training-related costs, it is not clear whether these foundations will be willing to pay for nonstipend fellowship costs. Without a solution to this problem, UCSF might be unable to avoid a substantial reduction in the size of what may be the most important postdoctoral and midcareer fellowship training program in health policy and health services research in the United States (UCSF Annual Report 1992-1993). UCSF finds itself in the paradoxical position of training an increasing number of exceptionally qualified follows while receiving a declining amount of support for core faculty and staff. UCSF continues to take great strides in making PHPP self-sufficient. UCSF faculty have implemented major steps toward the institutionalization of training. A series of new formal courses was developed and the curriculum has been enriched. Several courses have reached the stage of having structured syllabi with regular annual and biannual scheduling, and they attract a wide range of students and fellows from UCSF, the University of California at Berkeley, and other campuses. During the third cycle of Pew funding (1992 to 1995), a major part of the UCSF program's mission was to expand the support bases by attracting new sources of funding and midcareer fellows who were able to bring stipend support as well as pay the program for the cost of training. Brandeis University/Boston University The Pew doctoral program at Brandeis has enabled the Institute for Health Policy to broaden the health policy specialization in the Heller School curriculum. As of 1993, at least four courses developed through Pew funding were institutionalized at Brandeis (Advisory Board meeting, February 18, 1993). Because of the excellence of the Heller School's PhD program and the national reputation of the Pew doctoral program, many more students who are interested in careers in health policy research are becoming attracted to the program (Raskin et al., 1992). However, since the Pew

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The Lessons and The Legacy of the Pew Health Policy Program program funded only six students per year, many of these applicants have accepted the Heller School's offer to matriculate in the doctoral program and specialize in health policy. Because of this expanded interest in health policy, the institute has developed the Institute for Health Policy Fellows Program to help support some of these strong doctoral candidates. Selected students are required to follow the health policy core curriculum and participate in the weekly Seminar in Health Policy Research. In addition to the academic requirements, Institute fellows are required to work 1 day a week at the institute in exchange for a $7,500 annual stipend (Raskin et al., 1992). Joe Newhouse, who was on the faculty at RAND, built upon the RAND Pew experience in his new PhD program at Harvard University. In 1994, the Institute for Health Policy adopted the strategy of seeking health services research (as opposed to health policy research) training grants from the federal government to complete the transition to alternative funding. The Heller School was awarded training grants from the Agency for Health Care Policy and Research (AHCPR), and in 1995 the Heller School enrolled its first fellows in this program. The health services research training program's curriculum is very similar to that of the health policy research training program's curriculum, and the Heller School faculty believe that their success with the Pew programs greatly assisted them in receiving the AHCPR grants. The Pew program for corporate midcareer people that was housed at BU has been maintained; however, with the retirement of its director in 1996, its future is questionable. This was the only program of the joint BU-Brandeis program that was maintained at the BU campus, but this is less a result of discontinued funding and more a conscious decision by the university. RAND/UCLA According to Al Williams, the experience of the RAND/UCLA Pew program represents the real test of whether or not the Pew programs can be maintained after funding ends. The RAND/UCLA programs were defunded after the second funding cycle for the reasons discussed earlier. Although the schools were unable to maintain the midcareer program without support for the fellows, the Pew doctoral program in health policy studies became part of the regular doctoral program at the RAND Graduate School. RAND continues to train health policy fellows by using a multidisciplinary approach and with new funding streams. Furthermore, the success of the RAND/UCLA program has spawned new

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The Lessons and The Legacy of the Pew Health Policy Program The University of California at Berkeley may have been influenced somewhat by the Pew programs. Two former Pew fellows are teaching at UC-Berkeley and have carried over some of their graduate training experiences. health policy graduate training programs. Joe Newhouse, who was on the faculty at RAND, built upon the RAND Pew experience in his new PhD program at Harvard University. The University of Minnesota has also developed a stronger policy focus over time, and it may have been influenced by the Pew programs as well. Leighton Ku stated that the Johns Hopkins University's health policy program, a well-established program, has grown tremendously since the beginning of the Pew programs. Although he stated that he had no evidence that the Pew programs specifically influenced that growth, Ku speculated that some of the newer programs have likely been modeled on the Pew experiences. He also discussed the fact that the University of California at Berkeley may have been influenced somewhat by the Pew programs. Two former Pew fellows, James Robinson and Helen Schauffler, are teaching at UC-Berkeley and have carried over some of their graduate training experiences. Al Williams stated, "Imitation is a form of endorsement," and Dan Rubin agrees. Rubin asserts that, as a result of the theory of innovation diffusion, the prestige of the schools involved with the Pew programs and their subsequent successes with the innovative, nontraditional approaches to health policy training may have encouraged other universities to emulate their programs.