Alignment Before Apology: Transactional and Relational Dimensions of Reconciliation in Canadian Healthcare.

The purpose of this article is to introduce the Social Dynamics of Change (SDoC), a framework for institutional transformation, and examine the Canadian Medical Association's (CMA) 2024 Apology to the Indigenous Peoples of Canada as a case study in institutional reconciliation. Converging social, political, and institutional forces exposed the CMA's maladaptive relationship with Indigenous Peoples. Through the SDoC framework, reconciliation involved movement from crisis through denial, resistance, exploration, and commitment. Progress required relational accountability, trust, co-design, and sustained engagement between Indigenous and non-Indigenous leaders. The case highlights the importance of Indigenous leadership in senior governance, as three authors in distinct leadership roles helped create the enabling environment that supported the CMA's reconciliation journey. The CMA case suggests that meaningful institutional reconciliation is achieved when relational alignment precedes transactional milestones. The SDoC framework helps explain how healthcare organizations navigate change and translate reconciliation commitments into lasting shifts in governance and culture.