Acad Psychiatry (2014) 38:383–387 DOI 10.1007/s40596-014-0082-2

FEATURE: MISSIONS

Creating Opportunities for Organizational Leadership (COOL): Creating a Culture and Curriculum that Fosters Psychiatric Leadership Development and Quality Improvement Chandlee Dickey & Rodney Dismukes & David Topor

Received: 10 December 2012 / Accepted: 26 August 2013 / Published online: 25 March 2014 # Academic Psychiatry (outside the USA) 2014

Abstract The authors describe the Harvard South Shore Psychiatry Residency Training Program curriculum “Creating Opportunities for Organizational Leadership,” an innovative, multitiered, resident-driven, outcome-focused set of experiences designed to develop residents’ leadership skills in personal leadership, organizational leadership, negotiation, strategic thinking, and systems redesign. Keywords Psychiatry residents . Leadership . Curriculum development The future of psychiatry depends on educating and training clinical leaders. Recent reports suggest that 7 % of counties suffer from a severe shortage of psychiatrists [1] and 3.7 million uninsured Americans have serious mental illness [2]. This shortage is unlikely to improve given falling numbers of medical students entering into the field of psychiatry (14 % reduction from 2000–2001 to 2007–2008) [3]. How this shortfall will be managed by psychiatry leaders will have a major impact on clinical care delivery. The Affordable Care Act supports parity for mental health and addictions care, yet implementation of the Act is in its infancy [2]. Leadership from within the profession will be critical to guide the full development of these components of the Affordable Care Act. As such, the issue of whether to teach leadership and resource management in medical training can be construed as an ethical responsibility we owe our patients [4]. Management of resources requires leadership. The job of leaders is to lead and manage change. Leadership, as a construct, comprises disparate elements including personal leadership styles, emotional intelligence, strategic thinking skills, C. Dickey (*) : R. Dismukes : D. Topor Harvard Medical School, VA Boston Healthcare System, Boston, MA, USA e-mail: [email protected]

negotiation skills, motivational skills, organizational leadership, systems redesign skills, and operations skills [5–7]. Although there are many models of leadership, two major styles include an instructive, top-down, and coordinative style vs. a transformative, bottom-up, distributed, and empowering style [8]. For example, training directors might dictate curriculum and schedules or may empower residents and faculty to generate curriculum and set priorities. Fortunately, leadership skills, such as operations, financial management, informatics, strategy, and program development, can be taught [9]. Although traditional medical teaching has occurred by the bedside, organizational leadership learning has not been taught and requires a different approach [10]. For example, although didactics can provide a format for definitional acquisition, it cannot replace the necessary active experience of managing others [10]. Traditional chief resident positions offer this engaging opportunity, but these are limited in number and occur often without tacit instruction. There are a number of barriers to psychiatrists or other physicians pursuing leadership or administrative positions. In academic medicine, there may be a cultural bias against administrators such that administrators may be held in less regard than clinical or research leaders within a department [11]. Administrators, compared with productive clinicians and successful researchers, do not generate income for the hospital. The ability to generate funds is often a source of influence within a department. Psychiatry leaders may feel isolated from their clinically focused peers [11]. As emphasis for accountability and performance measures increases in medicine, those who monitor such measures may experience more separation from their clinical peers. Psychiatrists and other physicians may not pursue opportunities in leadership positions later in their careers given the investment they have made in developing and fine-tuning their clinical and research skills over the years [4]. Administration is time-consuming and that time requirement must be balanced with clinical, research, and

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family demands. Finally, in many academic centers, promotion criteria are not available for physicians whose primary focus is hospital administration [12, 13]. Taken together, these personal, cultural, work/life balance, and advancement issues may give pause to psychiatrists considering leadership roles. Integrating fundamentals of leadership development early in the psychiatrists’ careers, in medical school education, and graduate medical training, may lower some of these barriers. Indeed, institutions are beginning to weave leadership curriculum into medical education [9, 14–16] with curriculum designs varying between intensive one-day trainings to multiyear management experiences [9, 14, 15, 17]. Moreover, ACGME now requires that residents engage in quality assurance or quality improvement projects (http://www.acgme.org/acgmeweb/). The goal of the leadership curriculum at Harvard South Shore Psychiatry Residency Training Program (HSS) is to provide an innovative, multitiered, resident-driven, outcomefocused set of experiences designed to develop residents’ leadership skills in personal leadership, organizational leadership, negotiation, strategic thinking, and systems redesign (Table 1). This curriculum is called Creating Opportunities for Organizational Leadership (COOL) [18]. The organizing conceptual framework for these opportunities is that residents

will step up to lead organizational change initiatives when they believe it is stage-appropriate and when they believe they can make a difference. Thus, leadership experiences are provided repeatedly across all 4 years so that the resident determines when s/he is ready to learn (Table 1). Even if a resident is highly interested, s/he may have the more pressing need to learn psychiatry skills more deeply, and, hence, waiting on leadership skill development may be appropriate. These hands-on experiences are supplemented with traditional educational methods of didactic teaching and journal club discussions. For a resident with particular interest in leadership, the COOL curriculum can culminate in a systems redesign project encompassing up to 80 % time in the PG IV year. Referring to the previously mentioned models of leadership, either topdown and instructive vs. bottom-up and transformational, at HSS, we are blending both approaches. However, the predominant model is bottom-up and transformational. That is, residents are empowered to lead change at HSS. This level of emphasis and concentration of effort requires both the support of department leadership and the endorsement of the faculty. In short, it demands culture change [19] to one which explicitly values continuous quality improvement. Over the past 2.5 years, HSS has focused on developing and

Table 1 Description of the curriculum “Creating Opportunities for Organizational Leadership” Component

Format

Voluntary vs. required

Type of leadership

PGY PGY PGY PGY I II III IV

Class ombudsman

Experiential

Voluntary, selected by peers Personal leadership development

X

X

X

X

Lean training

Simulations, with increasing depths of experiences

Voluntary, strongly encouraged

Systems redesign: organizational leadership

X

X

X

X

Leadership in Complex Healthcare Systems Seminar

Seminar/journal club

Required

Personal leadership development

X

X

X

X

Mental Health Leadership Seminar

Seminar

Required

Operations, systems redesign, finance: all organizational leadership

Action teams, (member or leader)

Experiential

Voluntary

Systems redesign: organizational leadership and personal leadership development

X

X

Chief resident

Experiential

Voluntary, selected by training director, limited opportunity

Personal leadership development

Negotiation fishbowl

Simulation

Strongly encouraged

Negotiation skills: personal leadership X development

COOL elective

Experiential

Voluntary, selected via application process

Systems redesign: organizational leadership and personal leadership development

COOL (process team member)

Experiential

Voluntary

Systems redesign: organizational leadership

X

X

X

X

X

X

X

X

X

X

X

X

X

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implementing a curriculum to teach residents the fundamentals of leadership and how these skills are applied in healthcare settings. This culture shift provides an opportunity for modeling leadership: residents observe and participate in leading the curriculum change. For example, residents led the effort to create the COOL track and are leading implementation of milestones. By allowing the residents to lead, the training director models a transformational style of leadership. Moreover, steps of change are labeled to the residents as it is occurring (i.e., resistance to change, team development, etc.) so that residents develop a keen sense of how things are adapting as the change is occurring. Thus, residents are taught to observe leadership in action and to incorporate effective elements into their own leadership work. The specifics of the curriculum development for COOL fall under four broad categories: (1) leadership-focused didactics; (2) initial personal leadership experiences, including leading a quality improvement project; (3) participatory skill development workshops, trainings, and simulations; and (4) heavily mentored systems redesign project experiences. Successful involvement and completion of any of the last three of these opportunities is considered sufficient for a resident to meet the ACGME QA/QI project requirement. The overarching goal of the curriculum is to guide the resident in their personal leadership development while providing the knowledge of leadership skills and strategies to best apply these skills in healthcare settings through quality improvement projects. Table 1 encapsulates the various leadership learning opportunities at HSS. The description of these learning activities was deemed IRB exempt from VA Boston Healthcare System Institutional Review Board.

Leadership Didactics The Mental Health Leadership Seminar surveys the philosophy of leadership, types of healthcare delivery systems, facets of quality assurance, system-based risk management tools, and ethical considerations when leading a healthcare system. The semester-long PGY II course culminates in teams of residents creating a business plan. Business plans are commonly written by organizations to outline their goals and steps necessary to reach their goals. Increasingly, physician leaders are writing business plans to have profitable clinics. Providing the opportunity to write a hypothetical business plan as a resident is important for their careers. For example, these plans may describe revamping a clinic to decrease waste or enhancing patient flow. The second offering is a monthly journal club for all residents called Leadership in Complex Healthcare Systems that explores qualities of exceptional leaders.

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Personal Leadership Experiences In addition to the chief resident and class representative (class ombudsman) opportunities common to psychiatry residency training programs, HSS encourages residents to lead action teams. Action teams are resident/faculty task forces designed to study a problem, identify potential solutions, and implement changes. Action teams require direction and oversight by a faculty member and benefit greatly from creating a charter. A charter is a document that clearly outlines the problem to be addressed, delineates the project scope, and states deliverables expected (i.e., a list of products expected from the team). Residents find these leadership opportunities fruitful and fulfilling as they can tangibly see the outcome of their efforts. Residents feel efficacious as they work to shift the culture and improve the program through their participation in action teams. Action teams allow residents to positively contribute to enhancing the program for their own education and training and that of future trainees in the HSS program. The additional benefit of action teams is that they promote resident involvement, ownership, and responsibility for the quality of the residency program. Action teams diminish the divisive construct of resident vs. administration and rather provides a mechanism for residents to partner with faculty and engage in a quality improvement project. Systems-Redesign, Lean, and Negotiation Simulations Future leaders in psychiatry will need concrete tools for improving clinic efficiency and negotiating for increasingly scarce resources. Partnering with hospital quality improvement (QI) teams allows HSS residents to participate in lean trainings. Lean training is designed to provide tools for learners to use in systems redesign projects. Lean tools include ways of measuring waste and creating a new process that is more effective. Examples of waste include delays (such as long delays in scheduling patient appointments), redundancy of efforts (such as a nurse and doctor doing the same thing), and inefficient operations (such as poor patient flow through a clinic). Lean was popularized by the Toyota Production System, the efficient model of car assembly focused on continuous quality improvement and the elimination of waste (http://www.toyota-global. com/company/vision_philosophy/toyota_production_ system/). This year, residents will spend a morning learning elementary lean tools from a hospital-based systems redesign engineer and, in small teams, apply those tools in the afternoon to address a clinically relevant issue. Another simulation opportunity we employ addresses negotiation skills and conflict resolution. Residents need wellhoned negotiation skills yet have little to no training in negotiation. Residents learn how to prepare before entering into a negotiation by identifying the other side’s interests, outlining the best alternates to a negotiated agreement, and using

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effective communication techniques. Residents simulate these negotiations by participating in role plays, such as in a future job interview. Conflict resolution skills are also taught through simulation, where a partially scripted conflict is acted out, and residents discuss effective strategies as a group. Examples of the role play include discussing work load distribution with a chief resident [18]. These simulations have empowered our residents to think more critically prior to a negotiation and to decrease the affective component during negotiations.

COOL Track: Mentored System Redesign Elective For residents who are particularly interested in learning about leadership skills, HSS offers 10 % time in PG III year and up to 80 % elective time in the PG IV year to complete a systems redesign project of significant clinical impact. This COOL track is the pinnacle of our leadership offerings and can be considered analogous to a research track in that it requires an application outlining the project, mentorship, and clear expectations for product delivery at the end. Examples to date include revamping the inpatient admission process and introducing web-based self-assessment curriculum for patients on the detoxification unit. These COOL projects are created by the residents themselves, with guidance from their mentors. The COOL resident will have two mentors with whom they meet, one with clinical issue expertise and second with systems redesign expertise. Mentors are selected by the resident based on COOL topic and mutual interest, with guidance from the training director. Faculty with systems redesign expertise may come from outside the department, particularly persons with business or hospital administration degrees. In the course of the project, the resident forms and leads a multidisciplinary process improvement team, including fellow residents. These process teams identify and measure current inefficiencies in the system and design and implement an improvement. Three examples of COOL projects demonstrate the variety of projects and the depth of the commitment on the part of the resident and department. The inaugural project included redesigning the template note used during the patient admission process to our inpatient wards. The result was a reduction of admission time of 65 min. Another project entailed offering online substance abuse materials to patients during their detoxification admission to enhance patient substance use disclosure and decrease readmission rates. A final project was even more ambitious: moving resident outpatient clinics to a different location. Each of these examples required the resident to collaborate with colleagues and motivate others to engage in the change process. The purpose of this elective is to foster leadership skill development and to improve aspects of clinical care in the department.

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HSS’s sustained focus on leadership affects the perspective of the residents, perhaps even more than the faculty. A confidential and voluntary online survey was created to assess attitudes toward leadership education and training during residency and was completed over a 1-month period in the fall, 2011. Both residents (N=18) and faculty (N=18) respondents thought teaching leadership was important to psychiatric education (mean 4.9 out of 7 points, Likert scale). Residents were more likely than faculty to think that leadership skills could be taught and learned (F=4.720, p

Creating Opportunities for Organizational Leadership (COOL): Creating a culture and curriculum that fosters psychiatric leadership development and quality improvement.

The authors describe the Harvard South Shore Psychiatry Residency Training Program curriculum "Creating Opportunities for Organizational Leadership," ...
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