Future Hospital Commission, 10 years on - Lessons learned and next steps: The Chief Registrar Programme - what has been achieved?

The Royal College of Physicians (RCP) Chief Registrar Programme (CRP) emerged from the RCP Future Hospital Commission Report (2013) and aimed to address development of clinical leadership and quality improvement to maintain high standards of patient safety and experience. The 2016 pilot created a new senior leadership role recruiting doctors in training committed to quality improvement and leadership development to champion delivering change in trusts, supported by a year-long bespoke development programme designed and delivered by the RCP. Following validation of the pilot's impact, the CRP has evolved to become a 'flagship' programme for the RCP with increasing penetrance across the UK to maximise impact for chief registrars to lead and deliver quality improvement in trusts. The longer-term goal is that enthusiastic early leaders will deliver sustainable and impactful change regionally and in the wider NHS. This article seeks to explore the CRP development themes and reflects on the learning from the programme and the experiences of chief registrars. The CRP has evolved during a time of significant healthcare challenge with the programme delivering a future generation of medical leaders to navigate these challenges, deliver improvement and innovation across the health sector. We show how chief registrars and alumni can continue to drive forward widespread impact on individuals, organisations and the wider NHS, providing a strategic solution to meet current and future challenges in the NHS.

Role of emotions in change and change management in an emergency department: a qualitative study.

BACKGROUND: Changes in emergency departments are frequently implemented to improve efficiency and reduce costs. However, staff acceptance and adoption are crucial for the intended success of changes. OBJECTIVES: This study explored staff perceptions of factors influencing the implementation of changes and any common themes linking changes and factors influencing changes in an emergency department at a university teaching hospital in the UK. METHODS: We used constructivist grounded theory methodology to perform a secondary analysis of 41 interview transcripts of physicians, nurses, support workers and managers involved in paediatric emergency care. RESULTS: Participants identified leadership, communication and education as factors impacting change management. They described many emotions associated with changes and with communication, leadership and education or the lack of any of them during changes. Both positive and negative emotions sometimes coexisted at individual, team or organisational levels. Negative emotions were due to real-life challenges and concern over compromised patient care. Professional values dictated the actions or inactions that transpired either because of these emotions or despite these emotions in health professionals. CONCLUSIONS: Emotions to change should be acknowledged and addressed by credible leadership clear communication and education to improve the change process, its success and ultimately, patient care.

Evaluation of the first 5 years of the Next Generation GP leadership programme: balancing autonomy and accountability.

BACKGROUND: In 2017, a group of trainee general practitioners (GPs) came together to design and deliver a six-session leadership development programme for their peer trainee and early career GPs: the Next Generation GP programme. Over 2500 GPs took part in Next Generation GP between 2017 and 2022. AIM: To evaluate the origins and development of the Next Generation GP programme, its early impact on individuals and general practice, and what it reveals about GPs' needs for career and leadership development at a time of major workforce and demand pressures. METHODS: A rapid review of evidence on general practice workforce and career trends informed the design of qualitative research interviews (n=28) with a purposive sample of programme participants, primary care leaders and educational experts. This was supplemented by analysis of secondary data from participant evaluations of programme workshops. RESULTS: Many programme participants reported: improved competence in leadership skills, increased understanding of the health system, having new support networks and more energy for their GP role. Respondents pointed out the strengths of the programme, also highlighting ways in which it could be adapted to enable a transition to a more sustainable position within broader clinical and leadership career development. CONCLUSIONS: Next Generation GP has to date largely fulfilled its programme objectives. It now needs more tangible, longer-term objectives against which to assess outcomes. This evaluation has contributed to evidence about primary care leadership needing more policy attention, for the balance of autonomy and accountability within GP leadership needs careful and sustained support.

Building towards organisational resilience and complexity leadership: a case study of impacts and changes in a Dutch blood establishment during COVID-19.

OBJECTIVES: This study examined how one large blood-related establishment coped and adapted during the first 1.5 years of the pandemic by evaluating the impacts and changes on its resources, communication, collaborations, and monitoring and feedback. Furthermore, we explored whether elements of complexity leadership emerged during this time. DESIGN: Duchek's organisational resilience framework was primarily used. We followed a three-step sequential approach: (1) a document analysis of over 150 intranet, internet and internal reports; (2) 31 semistructured interviews with employees and (3) four feedback sessions. SETTING: Sanquin is known as the Dutch national blood bank and a large multidivisional expertise organisation in the Netherlands. RESULTS: Sanquin coped well. Respondents accepted the crisis and catalysed many collaborations to implement solutions, which were communicated to the public. There were many positive aspects related to internal collaborations, yet challenges remained related to its historical siloed structure and culture. Sanquin adapted partially. Many respondents experienced the organisation becoming more connected and flexible during the pandemic. However, Sanquin was not permanently changed due to significant leadership changes and organisational restructuring occurring simultaneously. Respondents reflected on lessons learnt, including the need for continual collaboration and improvements in Sanquin's culture. An important driver in the successful coping was management's enabling attitude and the adaptations occurring within and through the collaborative groups. CONCLUSIONS: Sanquin improved its organisational resilience by exhibiting elements of adaptive spaces, enabling leadership and (temporary) emergence from complexity leadership. This illuminates how the organisation could continue benefiting from complexity leadership for non-crises and for future uncertainties.

Cultivating the next generation of healthcare leaders: reflections from an established healthcare leader.

BACKGROUND: Dr Andrea Doria is Professor and Vice-Chair of Radiology (Clinical Practice Improvement) at the University of Toronto, Research Director, Senior Scientist and Imaging Lead of Personalised Child Health, The Hospital for Sick Children (SickKids), Toronto, Canada. Over the past few decades, Dr Doria has established a track record of healthcare leadership. Based on Dr Doria's extensive leadership experience, she believes it is essential for established healthcare leaders to be involved in cultivating emerging healthcare leaders. METHODS: An interview was conducted with Dr Doria to learn about key lessons she believes are essential for healthcare leaders to help develop the next generation. Dr Doria reflected on her leadership style and experiences, sharing what has worked to improve the effectiveness of her teams. RESULTS: Key messages were reflected upon, including practical ways for senior leaders to support the next generation; leadership insights gained from the pandemic; the importance of building diversity in teams and nurturing leaders from underrepresented minorities; challenges to be aware of for the future of healthcare leadership; finding inspiration from team members and essential traits for healthcare leaders. CONCLUSION: Through cultivating the next generation of healthcare leaders, established leaders can be involved in establishing a brighter future for healthcare. This article describes reflections and practical takeaways that can help established leaders support emerging leaders and build their leadership skills.

Emotionally intelligent themes in medical leaders' decision-making during COVID-19.

BACKGROUND: The COVID-19 pandemic presented unprecedented challenges for leaders in healthcare requiring decision-making and crisis response that can often be tricky without the right level of trust. Trust is fostered and facilitated with emotional intelligence (EI); thus, a critical examination of medical leaders' reflections was essential to understand how leaders perceived their leadership responses during the initial response to COVID-19. This exploratory study used an EI lens to investigate leaders' perceptions of their decision-making during COVID-19. METHODS: A purposeful sample of seven leaders in medicine who experienced leading during COVID were invited to participate in semi-structured interviews. RESULTS: Four themes around leadership response during the uncertain times of the COVID-19 were identified. The themes included communication, interprofessional collaboration including decision-making and strategic planning, internal and external awareness, and finally, trust and psychological safety. CONCLUSIONS: Incorporating EI competencies into crisis leadership education for healthcare professionals could enhance medical leaders' preparedness to adapt, collaborate and communicate effectively in a crisis.

Participation in staff engagement campaigns at large healthcare organisations: a focus group study.

INTRODUCTION: Healthcare organisations work better with an engaged workforce, and staff-engagement campaigns offer a method to build this engagement. Leeds Teaching Hospitals NHS Trust (LTHT), one of the UK's largest Trusts, provides an example of where an organisation-wide engagement intervention has been used in a healthcare setting. This study aimed to understand why staff participate, or do not participate, in staff-engagement campaigns, supporting healthcare leaders to increase participation in future campaigns. METHODS: Scenario-based focus groups were carried out across five different organisational units within LTHT. The data from these were transcribed, coded and analysed using reflective thematic analysis. RESULTS: Participation in staff-engagement campaigns is dependent on campaign awareness, staff perceptions of the campaign and the practicalities associated with participation. Perceptions of the campaign are further subdivided into the campaign's perceived effectiveness, purpose and relevance. CONCLUSIONS: Staff engagement was a powerful driver of participation, which presents a conundrum: how do you encourage participation in staff-engagement campaigns, if engagement is a prerequisite for participation? The answer lies in taking advantage of organisational belongingness and visible leadership, supported by communications that take control of the narrative around the campaign. Behavioural science models may guide leaders across the organisation in mapping where these approaches can have the greatest impact within their existing spheres of influence. Further, considering inequalities around participation across different groups may help target action to the areas of greatest need. Accordingly, the research provides pragmatic guidance for leaders in thinking about how to use staff-engagement campaigns more effectively.

Medical education needs a new model for global leadership.

BACKGROUND: Like other fields in medicine, medical education relies on collaboration and cooperation between countries and regions of the world, although no single institution or position unifies the global medical education community in the way that the WHO does in public health, for example. Recent research in medical education has drawn attention to many injustices that exist in the field, where power and influence is held in relatively few Global North countries, although most practice happens in Global South countries. METHODS: In this article, we examine three positions that hold global prominence in medical education, including the presidents of the World Federation for Medical Education and the Association for Medical Education in Europe, and winners of the Karolinska Institutet Prize for Research in Medical Education. FINDINGS: We highlight that these positions have problematic histories and have perpetuated the current power disparities in the field. We argue that an alternative model for global leadership is required that should be determined democratically by those involved in medical education all around the world. Such a model should prioritise diversity and inclusivity, empowering leaders from countries who have previously been peripheral to the decision-making platforms in the field. CONCLUSION: Given the shortcomings of existing leadership positions and organisations, we suggest that a new institution is required to realise this new vision, and that the principles that govern it should be determined through debate and democracy, with a focus on inviting those voices that have not previously been heard in global medical education circles.

Kindness in healthcare leadership and management: an evaluation and analysis of the concept.

BACKGROUND: Healthcare leadership and management impacts every patient journey and every staff experience. Good leadership results in positive outcomes. Kindness is an understudied and underused leadership strategy. The research questions addressed in this study are the following: (1) Does kindness in healthcare leadership and management currently meet the criteria of a mature concept?; (2) Using concept analysis methodology, can we develop our understanding of kindness within this context? METHODS: A systematic search of the peer-reviewed literature was conducted to inform a concept evaluation, followed by a concept analysis. Search terms consisted of 'leader*' or 'manage*' and 'kindness'; databases searched comprised MEDLINE, HMIC, SPP, APA PsycInfo and CINAHL. Data extraction and thematic analysis of the data were performed manually according to concept analysis principles. RESULTS: The 10 papers included from the search suggested that within healthcare leadership and management, kindness is an 'emerging' rather than a 'mature' concept. Concept analysis demonstrated a cluster of recurring attributes, allowing a theoretical definition to be put forth. CONCLUSIONS: Despite being a commonly used lay term, kindness in the context of healthcare leadership and management is not yet a mature concept. Work developing this concept is needed to validate the proposed theoretical definition. Observational studies and systematic review of the grey literature are recommended.

An evaluation of the West of Scotland in-programme Chief Resident role.

Background: Postgraduate leadership education is an evolving field. Locally we have an established 'Chief Residency' programme where centres have two to four senior trainees completing leadership duties alongside clinical workload, supported by local directors of medical education. This is twinned with a 4-day central training programme and peer-support network. Methods: To assess perspectives of the CR role, we adopted a qualitative case-study design using an electronic questionnaire delivered to previous chief residents between 2020 and 2023. Results were analysed using thematic analysis. Results: Trainees valued involvement within quality improvement and trainee support, demonstrating successful multi-departmental projects. Leadership education was viewed ubiquitously positively but participants felt further work is needed to address role legitimacy locally. A proposed solution was junior doctor leadership teams to address workload and emotional challenges. Conclusion: This model provides further evidence of the value in investing in trainee leadership positions, demonstrating organisational impact. Future work will research hospital peer leadership teams.

Curriculum mapping to audit and grow longitudinal graduate medical education leadership training.

BACKGROUND: Residents need and want practical leadership training, yet leadership curricula are lacking in graduate medical education (GME). We describe our process of curriculum mapping, a method for auditing a curriculum, and its role in iterative leadership curriculum development. AIMS: To show how to create a curriculum map for auditing a curriculum using examples from our leadership curriculum and to demonstrate its value through case examples of leadership education integration into existing resident experiences. METHODS: We selected our recent systematic review on current leadership curricula to prioritise leadership content given it was the basis for our initial curriculum. We identified existing resident experiences where training can occur. We use the selected content and training environments, layered with a modified Miller's pyramid, to construct a curriculum map. RESULTS: Our curriculum map provides an example of curriculum auditing that reveals opportunities for leadership training that could be integrated into current residency experiences. We provide case examples of application. DISCUSSION: Effective leadership training should address critical topics and capitalise on experiential learning opportunities that exist within residency training programmes. The training must be seamlessly integrated into the demanding obligations of GME trainees, a process that can be achieved using curriculum mapping. Curriculum mapping can provide insight into a residency programme's leadership curriculum and create a direction for future leadership curriculum development.

History and its relevance to contemporary and future leadership.

BACKGROUND/AIM: This paper argues that an inquisitiveness into the history of medicine and healthcare organisation is an important characteristic of a leader seeking to understand why facts are as they are, before embarking on leading change. I had the privilege of 34 years of service in the UK Defence Medical Services, culminating in the most senior role of Surgeon General. I, and many of my military medical colleagues, are members of the Faculty of Medical Leadership and Management. Through this, I hope that we have been able to add an interesting dimension to the practice of medical leadership in UK health organisations. METHODS: This paper is a reflection on my personal experience suggesting that studying the history of military medicine can provide insights into the collective knowledge of previous generations, the process of organisational development during war, and the clinical and system innovations needed for the next war. RESULTS: This paper summarises my personal experience of the relevance of the history of military medicine in clinical practice and policy development within the UK Defence Medical Services. It has five sections starting with history as a trajectory of knowledge, and how this links to my personal career. I then show how history informed my leadership influence on policy and practice in four topics: the prevention of heat illness, the organisation of medical services, partnerships in military medicine, and organisational learning. The paper is framed around my personal experience over a career that spanned clinical practice, policy development, leadership on military operations, and finally senior strategic roles. CONCLUSION: While I have placed my argument in the context of military medical leadership, I suggest that understanding history is just as important in civilian medical leadership.

How the 'Health Leader-as-Coach' benefits health leaders, their teams, peers, organisation and the system.

One of the main ways in which health leaders at all levels can be developed on a daily basis has been neglected by clinical leadership research, and by the research community generally, relating to the leader consciously using evidence-based coaching skills to positively impact their direct reports, team members, peers, organisations and the wider system in the context of their vocational role, as 'Leader-as-Coach'.This paper summarises the research on the role of 'Leader-as-Coach', and translates the learning from this into the practice of clinical leadership development.Line managers are increasingly expected to use a coaching approach and are in an ideal position to do so. While there are many similarities with professional external coaching, the behaviours of the 'Leader-as-Coach' are also not identical and multiple ethical issues can arise.There is no consistent academic definition to describe the behaviours of coaching in the context of a leader's vocational role, nor yet specific competencies for training or supervision purposes.The outcomes are summarised from the known literature in this field. Individual and system challenges are then discussed and conclusions are drawn about what this research means in practice for clinical leaders and their systems.

Striving for equity: exploring gender-inclusive medical leadership in India.

INTRODUCTION: There is a notable gap in studies examining the impact of gender within sociocultural norms in non-western professional settings, especially concerning the well-being of women physicians. METHODS: Using purposive sampling and thematic data analysis, we recorded interviews with 30 physicians in India during May-July 2023. Participants were aged 34 to 65 years, with experience ranging from five to 35 years, in various clinical (37%), surgical (30%), paraclinical (23%) and hospital administration (10%) roles, 97% were postgraduates and 53% were women. The research questions explored how leadership roles happened, managing key challenges, barriers and enablers, and practical interventions to support women into medical leadership positions. RESULTS: Findings revealed that the majority of interviewees believed gender-related barriers were obstructing women's progress and success in medical leadership roles in India. These barriers were identified within three overarching domains: (1) specialty, (2) organisational and (3) sociocultural. Interviewees commonly acknowledged the male-dominated landscape of medical leadership although some women stated that they did not perceive any barriers for women's advancement into leadership roles. Interestingly, some men surgeons held the perception that women might not be as effective in certain surgical disciplines, such as orthopaedics and neurosurgery. Some men physicians, however, considered women physicians in India to be highly effective multitaskers. CONCLUSION: We recommend structural reforms in medical education, leadership development, workplace systems and cultures, and improved implementation of equality, diversity and inclusion policies in the Indian context.

Psychological safety in the perioperative environment: a cost-consequence analysis.

INTRODUCTION: Psychologically unsafe healthcare environments can lead to high levels of staff turnover, and unwanted financial burden. In this study, we investigate the hypothesis that lower levels of psychological safety are associated with higher levels of turnover, within an anaesthesiology department and we estimate the cost attributable to low psychological safety, driven by turnover costs. METHODS: Psychological safety was measured in one academic department. The psychological safety score was correlated with 'intention to leave' using linear regression and Pearson correlation and a cost-consequence analysis was performed. RESULTS: One hundred and thirty-eight physician anaesthesiologists (MDs) and 282 certified registered nurse anaesthetists (CRNAs) were surveyed. The response rate was 67.4% (93/138) for MDs and 60.6% (171/282) for CRNAs. There was an inverse relationship between psychological safety and turnover intent for both MDs (Pearson correlation -0.373, p value <0.0002) and CRNAs (Pearson correlation -0.486, p value <0.0002). The OR of intent to turn over in the presence of low psychological safety was 6.86 (95% CI 1.38 to 34.05) for MDs and 8.93 (95% CI 4.27 to 18.68) for CRNAs. The cost-consequence analysis demonstrated the cost of low psychological safety related to turnover per year was $337, 428 for MDs and $14, 024, 279 for CRNAs. Reducing low psychological safety in CRNAs from 31.6% to 20% reduces the potential cost of low psychological to $8 876 126.03. CONCLUSION: There is a cost relationship between low psychological safety and turnover. Low psychological safety in an academic anaesthesiology department may result in staff turnover, and potentially high financial costs.

Crafting Tomorrow's Medical Leaders: Insights from Medical Students and Interns in Saudi Arabia.

Introduction: Leadership is increasingly recognized as a crucial competency in medicine, with physicians expected to provide leadership skills throughout their careers. This study explores the perceptions, attitudes, and interests of medical students and interns in Saudi Arabia regarding medical leadership. Medical graduates are expected to "provide leadership skills that enhance team functioning, the learning environment, and the healthcare delivery system", according to the Association of American Medical Colleges (AAMC). Methods: A cross-sectional study was conducted from January to July 2023, involving 519 medical students and interns in Saudi Arabia. An online survey covered demographic data, perceptions, attitudes, interests, and self-perceived leadership skills. A pilot study was conducted to ensure the questionnaire's validity and reliability. Data were analyzed using SPSS 26, employing descriptive statistics and inferential tests. Results: Most participants had a positive perception of leadership (38.3%), with higher scores associated with medical specialties as a career choice (p < 0.001). The majority expressed average interest in medical leadership (29.1%). Communication and organizational skills were highly self-rated leadership attributes. Barriers to leadership implementation included lack of interest (49.3%), inadequate training (45.1%), and time constraints (43.2%). Only 14.6% rated leadership education in medical school as "very good". Conclusion: This study underscores the importance of leadership in medical education. Integrating comprehensive and structured leadership programs into medical curricula, addressing barriers, and promoting awareness can foster future medical leaders. Continuous evaluation and adaptation are essential for ensuring the relevance and effectiveness of leadership training.

Bringing people together through shared purpose and identity: lessons learnt from NHS Providers CEO Sir Julian Hartley.

INTRODUCTION: The healthcare sector is facing increased demand with reduced resources, yet despite these challenges, leaders such as NHS Providers CEO Sir Julian Hartley have created cultures where the workforce can realise shared values, through a focus on staff engagement. This article describes Julian's journey, through the eyes of a doctor-in-training working in an organisation he has led, to understand what we can learn from his approach to leadership. NARRATIVE: As a manager, Julian saw how many different people it takes to make the NHS work, and decided the role of an NHS leader was to bring people together, through a strong sense of shared purpose and identity. As CEO of Trusts in Blackpool and Leeds, he put this focus on staff engagement into practice to great success. Julian then introduced lean methods that flourished in the culture he had created, and when external factors such as COVID-19 began to erode that culture, returned to refresh that underpinning shared purpose. REFLECTION: Julian has developed a toolkit of behaviours and approaches, refined through experience and reflection, to help him elucidate and bring to life both the values and goals of the workforce. Because he shares these values, he has been able to lead with authenticity, creating engaged workforces, empowered to drive continuous improvement. We can reflect on Julian's approach as leaders ourselves: how can we align the values and visions of our staff, and ensure they are empowered to realise both?