A shift in leadership through shared training

There has been an emphasis on developing leadership skills for all clinicians and managers in the NHS since Lord Darzi’s Next Stage Review in 2009 highlighted the importance of strong leadership at a local level to set standards for high quality personalised care.

‘The programme is structured to give the residents an overview and deeper understanding of the hospital’s financial and management structure’

A King’s Fund report also recommended that skills were devolved across every level within each trust. The national aim is to move to a system of leadership that is “shared, distributive and adaptive”. With this in mind, our local director of medical education set up a senior residents’ programme. 

The main aim of the programme is to ensure that a number of senior trainees are given structured support and encouragement from leadership supervisors (consultants with a history of supporting trainees) in developing and demonstrating their leadership skills.

It also contributes to Royal Surrey County Hospital Foundation Trust’s local Creating the Culture for Continuous Improvement programme (C3i) every academic year. The concept of the senior resident’s programme echoes the now defunct senior registrar post, with senior trainees acting as the lead junior doctor within their specialty, linking consultant colleagues and management. Although there had previously been numerous leadership opportunities for trainees, uptake was poor. 

Underlying principles

The programme was first introduced to trainees in the October 2012 intake at Royal Surrey County Hospital. Eleven residents were chosen across different specialties following an application process and interview. The underlying principles followed the aims set out by the Kent, Surrey and Sussex Deanery leadership programme.

‘The methodology is designed to ensure that the trust has a common language and framework for any change management and service improvement work’

The programme is structured to give the residents an overview and deeper understanding of the hospital’s financial and management structure, and to encourage them to take some responsibility for leading change within their specialties. Monthly meetings form the cornerstone of the programme and each resident is expected, in turn, to set an agenda, chair the meeting and review the minutes prior to circulation. 

The residents are also asked to consider trust-wide issues and solutions between them and to take these back to their departments. A speaker is arranged for the second half of the meeting to give residents insight into the roles of the senior leaders. 

Speakers have included the chief executive, medical director, associate dean, a non-executive director and the director for transformational change. 

Residents are provided with a list of times of important meetings within the trust, including specialty business unit meetings, board meetings and local faculty group training meetings, and are encouraged to attend and reflect on leadership.

Decoding the objectives

One of the primary objectives of the programme was the completion of a service improvement project within the trust’s C3i framework. “Lean” working practices are increasingly used to drive service development in many public sector and private organisations. 

Each senior resident attended a two day Yellow Belt course, aimed at introducing them to the principles of service development. “Decoder” (define, establish, create, organise, do, evaluate and refine) is a continuous improvement framework developed specifically for the trust; it combines the basic elements of project management, Six Sigma tools and core lean principles.

‘Junior doctors instinctively gravitate away from hospital management and concentrate on day to day patient care’

The Decoder methodology is designed to ensure the trust has a common language and framework for any change management and service improvement work. It also allows staff to really understand what it is they are trying to fix and to collect data and evidence to show how things are performing before coming up with solutions to fix the root causes of the problem.

In contrast to the less structured approach typical of most clinical audit projects, this approach ensures each service improvement project focuses on delivering value to the customer.

Improving the service

Yellow Belt projects included introducing a weekend handover meeting within the Department of Medicine. The importance of good handover is well recognised, particularly since the introduction of the European Working Time Directive and shift work.

There was no verbal patient handover within the department of medicine between outgoing ward teams on a Friday and incoming on-call weekend teams. The project set about trying to introduce a weekend verbal handover to involve medicine, critical care and the site nurse practitioners; this now runs routinely on a Friday afternoon.

Local GPs had alerted the orthopaedic department they were increasingly dissatisfied with the emergency referral process. Following meetings with GPs and the department, a pilot study has started. 

New lines of communication include:

• the provision of a direct landline number for GPs to contact the emergency assessment unit;
• a shared mobile phone number for the on-call orthopaedic registrar for advice; and
• a fax number for urgent fracture clinic referrals.

A business card with these details has been sent to local GPs. We are monitoring the process and auditing complaints and satisfaction scores.

Discharge lounge use had been sporadic. Every morning, the surgical short stay/23-hour surgery unit became very congested as new patients arrived for surgery before the previous day’s patients had been discharged.

We negotiated early opening of the discharge lounge so patients staying overnight on surgical short stay could go there in the morning at 7am, where they could wait for their prescriptions and transport. A re-audit has shown a 20 per cent increase in overall use of the discharge lounge, with the 15 per cent increase in opening hours.

There is a tertiary referral hepatobiliary and pancreatic surgery service within the trust. There had been a long identified need for a more detailed internet presence, as requested by patients, GPs and referring hospitals. A new website incorporating these requests has been set up. 

Open communication

Junior doctors instinctively gravitate away from hospital management and concentrate on day to day patient care. In the modern NHS, aspiring consultants must engage with management on equal terms, looking to improve services by collaboration and responding to changes in demands.

Doctors in training face many competing demands, both professional and domestic. These include achieving clinical training requirements, completing audits, and undertaking and publishing research. This must all be balanced with family commitments and free time. Participation in service changes can be a low priority without specific guidance and encouragement.  

‘Lines of communication have improved and the senior residents have become identified as a group of problem solvers within the trust’

There have been teething problems. Consistent turnout at the monthly senior residents’ programme meetings was initially a problem. As a group, we have experienced the difficulties of balancing clinical commitments with the meetings, challenging our time management and organisation. Chairing the meetings has given each of us insight into this difficult skill.

The Yellow Belt course and the service improvement projects have been central to the programme, giving meaningful insight into the difficulties of effecting change within a large organisation. 

When there were practical difficulties such as a lack of IT support, discussions at the monthly meeting often helped to provide new solutions to allow projects to progress. Lines of communication have improved and the senior residents have become identified as a group of problem solvers within the trust.

The senior residents’ programme has provided an ideal platform to learn how a hospital functions behind the scenes. Completed service improvement projects have yielded tangible benefits for the trust, such as increasing throughput in the short stay unit, increasing patient safety through better handover practices and improving patient and referrers’ experience by changes in information sharing. 

We would encourage other interested clinicians to set up their own similar programmes locally.

Ajay Belgaumkar is specialist registrar general surgery, Julian Foote is specialist registrar orthopaedics, Dr Nick Smallwood is specialty registrar acute medicine, Dr Georgina Fraser is specialty registrar obstetrics and gynaecology, and Yogeesh Kamat is senior fellow, orthopaedics at Royal Surrey County Hospital Foundation Trust