Operationalizing Social Accountability through Governance – A Qualitative Study:  Perspectives of Senior Leaders in a Canadian Medical School

<ns3:p>Background Social accountability (SA) in Canadian medical education is codified in Committee on Accreditation of Canadian Medical Schools (CACMS) Element 1.1.1, yet how faculty-level governance enables social accountability remains underspecified. Objective To explore how senior leaders perceive current governance, identify gaps, and surface actionable reforms to operationalize social accountability. Methods We conducted semi-structured interviews with 34 leaders (decanal members, department heads, research institute directors, and nonacademic executives) at a large Canadian medical school (Sep–Nov 2022). Using reflexive thematic analysis, we iteratively developed themes, supported by memoing, team debriefs, and participant feedback on synthesized interpretations. Results Senior leaders identified a number of strengths to current governance models as well as three cross-cutting gaps: Leaders valued efficiency and familiar channels (single voice, decisional speed) but described tradeoffs: compressed consultation, path dependency, and change aversion (accountability gap). Leaders emphasized that enduring relationships—across leaders, units, and communities—are key to good governance and that honest, self-critical relationships are needed to drive shared understanding (relationality gap). Leaders also described capacity constraints and an operations-first focus that produce reactive decisions and crowd out inclusive engagement (responsiveness gap). Despite expressing a lack of confidence to solve these problems, leaders proposed structural changes (enshrine Indigenous self-determination via parallel pathways; embed civil-society organizations and Indigenous Nations at the faculty level) and procedural changes (adopt consensus-based decision-making; facilitated “third spaces” to dialogue on complex issues; and transparent “what we heard/what we did/what changed” feedback loops). Conclusions Inclusive governance is constitutive of social accountability by embedding in institutional design who is at the table and how decisions are made. Embedding comprehensive community-level representation and deliberative practices offers a feasible pathway to align mission, admissions, curriculum, and learning environments with codefined community priorities, thereby operationalizing social accountability standards named in CACMS 1.1.1.</ns3:p>