This empirical, descriptive study enriches the understanding of how institutional leaders navigate the complexities of major medical curriculum changes. The insights serve as a foundation for training and coaching future change leaders. To broaden the understanding of curriculum change processes, future studies could investigate the processes through alternative stakeholder perspectives.

In the midst of continuous health professions curriculum reforms, critical questions arise about the extent to which conceptual ideas are actually put into practice. Curricula are often not implemented as intended. An under-explored aspect that might play a role is governance. In light of major curriculum changes, we explored educators’ perspectives of the role of governance in the process of translating curriculum goals and concepts into institutionalized curriculum change at micro-level (teacher–student). In three Dutch medical schools, 19 educators with a dual role (teacher and coordinator) were interviewed between March and May 2018, using the rich pictures method. We employed qualitative content analysis with inductive coding. Data collection occurred concurrently with data analysis. Different governance processes were mentioned, each with its own effects on the curriculum and organizational responses. In Institute 1, participants described an unclear governance structure, resulting in implementation chaos in which an abstract educational concept could not be fully realized. In Institute 2, participants described a top–down and strict governance structure contributing to relatively successful implementation of the educational concept. However it also led to demotivation of educators, who started rebelling to recover their perceived loss of freedom. In Institute 3, participants described a relatively fragmentized process granting a lot of freedom, which contributed to contentment and motivation but did not fully produce the intended changes. Our paper empirically illustrates the importance of governance in curriculum change. To advance curriculum change processes and improve their desired outcomes it seems important to define and explicate both hard and soft governance processes.