Hitting new heights
A year on from its introduction, the chief resident programme at Cambridge University Hospitals is being expanded, write Jessie Welbourne and colleagues.
The chief resident programme at Cambridge University Hospitals Foundation Trust is a healthcare management and leadership training programme for senior trainees who have the potential to become the clinical directors and leaders of the future. It was developed out of the North American “chief resident” role, where each division has one senior trainee who has a range of administrative, pastoral and managerial roles.
The objectives of the programme are to learn the principles and theory behind healthcare leadership and management and to apply these in clinical practice by completing service improvement projects. As such, it represents a credible alternative to the Darzi fellowship, which can be replicated in many trusts around the country.
The programme is based on two main components: service improvement and training.
The service improvement element means that each chief resident is responsible for acting as a conduit of information between their consultants, managers and trainees for their service division. They are expected to disseminate relevant trust information to their trainee colleagues with the aim of better informing them and improving engagement with trust issues. These issues are discussed at a bi-monthly chief residents’ forum, chaired by the medical director and director of postgraduate medical education.
The second core area of service improvement is to design and execute service development projects, both as individuals and in groups. Each chief resident identifies an area within their clinical environment where there is potential for service improvement. With the involvement of the divisional directors these projects are intended to serve as a way of putting the theory learned in the training component into practice while improving service delivery.
Arising from the forum meetings, general areas for development are also identified and tackled in groups by the chief residents.
The training component requires attendance at the management and leadership development programme, run by the University of Cambridge Judge Business School. This includes 10 one-day modules based on the core modules of an MBA, including: setting the healthcare context; strategy; health economics; accounting and finance; operations management; management practice and working together in teams; marketing; innovation; and organisational behaviour and leadership.
It also involves participation in departmental, divisional management and educational related meetings. These meetings are important for understanding the basics of how departments and directorates operate and so provide valuable educational experience.
Finally, a healthcare management simulation day is mandatory for all chief residents, consisting of a bespoke training course using simulation facilities to develop real-time exercises based in the hospital. This includes facing and acting on a threatened confidentiality breach, a publicity disaster and methods of providing constructive feedback to team members.
Unlike the Darzi fellowships, there is no backfill for the chief residents’ time to fulfil the functions described above. The cost for the bespoke healthcare simulation day is borne by the Addenbrookes Simulation Centre. A negotiated fee for the CJBS component is covered by funding given by the East of England Deanery and the CUH Postgraduate Centre.
In the first year of the programme, 11 chief residents were appointed, all of whom were near their certificate of completion of training and expected to be in the post for the whole year. They represented the major service divisions: medicine; surgery; investigative sciences; perioperative services; women’s and children’s; and neurosciences. The appointments were made after a competitive process consisting of a written submission followed by an interview with the director of each division, the director of postgraduate education and the medical director.
Individual service improvement projects
All the chief residents undertook an individual service improvement project. Some of the projects included:
- Service optimisation - four chief residents from different divisions tackled the optimisation of blood test requests within their divisions. Each used different models and approaches but all managed to effect reductions in the number of inappropriate tests requested. Longer-term, sustainable changes to the processes involved were addressed.
- Service expansion - although considered to be already operating at full capacity, the living donor kidney transplant programme was successfully expanded through a strategy from the surgical chief resident.
- New service introduction - a new intervention in sexual and reproductive health was introduced. Although funding was not granted despite the potential for long-term savings, the chief resident was successful in introducing a new service, which improved contraception services after termination of pregnancy.
The chief residents tackled a number of problems informed by surveys of junior doctors across the hospital. Examples of these included: methods of communication with juniors; local departmental induction; education; and problems highlighted by national surveys.
The purpose of the Cambridge Judge Business School programme was to introduce the chief residents to the language, mindset and fundamental concepts of good management. The combination of the chief residents’ project experience, the faculty’s expert knowledge across many industries, and a mix of healthcare and industry case studies inspired the chief residents to think about their clinical practice from the perspective of a company manager.
First year feedback
The chief residents completed an assessment of the initiative. The response rate was 82 per cent and the feedback covered the overall programme, the taught element and the projects. Overall, it was rated an excellent programme and considered highly relevant to their future careers. The results from the feedback were taken forward in the adaptations made to the next year’s programme.
- Interacting with senior trainees from other specialties helped in the realisation that many problems were common to all specialties and that ideas and experiences could be shared.
- Improved lines of communication between junior doctors and medical staffing.
The process of leading a management project provided a “safe” environment for the chief residents to tackle common problems facing managers and clinical leaders across the NHS and other workplaces. While each resident learned from their individual activities within their division, a number of common themes emerged:
- Selecting an appropriate project that was deliverable within one year. Recognising the problems in selecting, specifying and delivering appropriate service improvement projects is an important part of the learning process and is widely experienced by clinical leaders.
- Change in clinical practice to effect a cost saving for the organisation. Most of the chief residents encountered difficulties associated with tariffs, coding and savings made across departments.
- Personal development. The role demonstrated how appropriate confidence, mindset, leadership and management skills affect change and make a marked difference to their organisation.
Common learning points for all the chief residents included:
- engaging stakeholders - implementing change management;
- putting management theory into practice;
- time management balancing clinical and managerial responsibilities.
These issues were tackled in the taught CJBS component and encountered in the hospital- based service improvement roles, and were valuable training points for life as a consultant and clinical manager.
Planned progression of the programme includes measuring the change in the chief residents’ managerial and leadership skills before and after completion of the programme. These will include 360 appraisals and a simulator session, in order to provide a quantifiable measure for comparison.
The management and leadership development course with the Cambridge Judge Business School received a very positive response. Adaptations to the structure and content are being incorporated into future programmes to better align them with the projects, while maintaining regular group sessions throughout the year.
The remit of the individual projects will be more clearly defined and coordination of projects between chief residents to improve service delivery will be encouraged. It is hoped that as the programme evolves, the benefits for the individual chief residents will be matched by benefits for the trust through improved services. Chief residents could take the lead on long-term projects that lead to larger cost savings.
The skills learnt through the chief resident programme are valuable to all hospitals looking to improve and expand, while providing a competitive service.
Just as the chief resident role was new, the divisional directors were new to working with the chief residents. In the subsequent year of the programme, the chief residents are better equipped to seek appropriate support from their divisional directors by having a clearer set of objectives.
This year’s expansion of the chief resident role has brought about many varied benefits through education of the individual chief residents and through service improvements. The programme has proved to be feasible and worthwhile for service provision to the trust and postgraduate education.
Specific improvements include improved communication with junior doctors across the trust, the introduction of initiatives that have improved quality of care and reduced costs in relation to investigations and optimisation of the use of some existing services.
More non-specific or less tangible improvements include general education of this group of senior trainees in the structure of the NHS and the subsequent important influences this will have on hospital trusts in the future. This has been achieved though regular contact between the trainees and high-profile figures within the hospital and through the chief residents attendance at the CJBS.
Dr Jessie Welbourne is a locum consultant in anaesthetics and critical care, writing on behalf of the chief resident cohort 2010-2011. Dr Arun Gupta is director of postgraduate education, Cambridge University Health Partners Academic Health Sciences Centre. Stefan Scholtes is the Dennis Gillings Professor of Health Management, Cambridge Judge Business School. Dr Jenny Dean is the former executive director, Centre for Health Leadership & Enterprise, Judge Business School, Cambridge University. She is now associate director, KPMG Advisory. Dr Jag Ahluwalia is medical director at Cambridge University Hospitals Foundation Trust.
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