Criteria for Excellence | Chapter 2: Residency leadership and management

Authors: Diana Heiman, MD; Walt Mills, MD; Elissa Palmer, MD

Successful residency leaders manage a complex set of relationships with stakeholders to obtain the resources necessary to sustain—and grow, if appropriate—the family medicine workforce needed to serve their communities, both directly and indirectly (i.e., through graduates’ practices).¹ These resources may include faculty, staff, residency positions, capital, space, and information technology (IT). A residency leader must have a deep understanding of shareholders’ values, mission, and vision in order to articulate a compelling shared vision that connects the residency program and its services to the community.

At a time of great change, organizational leadership capacity within a family medicine residency program needs to be robust enough for the program to successfully navigate the change process. Programs need a more collaborative, team-based model of leadership to ensure that everyone in the residency is engaged in efforts to achieve the program’s vision. This vision should be customer oriented from both the patients’ point of view and the learners’ point of view.

Build an adaptable, team-based residency leadership model

Given the complexities and high stakes of leading a residency, it now requires a team. The leadership team in a Program of Excellence uses adaptive leadership to competently respond to changes in its parent organization, the health care market, and regulatory requirements. A Program of Excellence is able to adapt to these changes while continuing to produce high-quality graduates who can practice a broad scope of family medicine independently and use newer models of patient care to provide a satisfying experience and excellent health outcomes.

The leadership team should be actively engaged in programs that alert them to
changes in the science of education, the clinical practice environment, the health care system, and accreditation requirements so they can anticipate changes and proactively address them in the curriculum. In addition, the team should be able to manage the program through a crisis (e.g., unanticipated loss of a resident or faculty member, pandemic) and still have enough resilience to function effectively. They should also maintain adherence to all institutional, common, and program-specific Accreditation Council for Graduate Medical Education (ACGME) accreditation requirements.

The rate of change in graduate medical education continues to accelerate. Traditional hierarchical management structures can hamper quick and efficient adaptation within residency programs. To keep pace with current ACGME requirements, evolving reporting processes, and evolving models of education (e.g., competency-based medical education, master adaptive learning), residencies must be adaptable, collaborative, and innovative. Day-to-day demands often command the most attention, so programs must be proactive to minimize change fatigue when they institute broad changes that require effective leadership. Financial, operational, and psychological support from the sponsoring institution and community may be limited, especially if the
family medicine program seems isolated from that support.

Develop residency leadership skills and succession plans

Many family medicine residency leadership teams have not been adequately trained in leadership. Programs of Excellence engage each member of their leadership team in both team development and an individual leadership development program. Mentorship, executive coaching, adequate protected administrative time, and succession planning are essential. In a Program of Excellence, envisioning the team’s “leadership legacy” guides development and actions. Adopting newer processes and business techniques helps facilitate organizational adaptability and resilience.

Programs of Excellence prioritize strategies to identify and implement process
improvements. (See the Quality Improvement and Patient Safety section for additional information.) A Program of Excellence encourages the entire organization to adopt and utilize process and quality improvement tools as part of ongoing operations and curricular improvement efforts.

Key actions to successfully lead change in the residency program

The leadership team of a family medicine residency program should stay apprised of and embrace newer management and leadership techniques​ that can help the program adapt to change effectively. To successfully lead change, program leadership will also do the following:

1. Establish a compelling strategic vision for the clinical practice and the
   family medicine program overall: This vision includes education, scholarly activity production, and leadership development. It is customer oriented and detailed and has a scope that can be rolled out over a three- to five-year timeframe. The vision is well planned but not so rigid that it cannot adapt to changes in the environment or available resources. (See the Strategic Planning chapter for additional information.)
2. Measure key outcomes to ensure goals are achieved: It is often said that
   “you can’t manage what you can’t measure,” so the leadership team must measure outcomes of their training program. A Program of Excellence leverages the ACGME Program Evaluation Committee (PEC) to generate metrics and action plans in their Annual Program Evaluation Action Plan that meet and exceed the ACGME requirements. These measures are organized into a scorecard that is periodically published and displayed for all to see, not just submitted in the ACGME Web Accreditation Data System (WebADS). This scorecard serves as a foundation for improvement activities that engage all stakeholders.
3. Engage in vigorous debate about key organizational decisions and, once a decision is made, align the team to accomplish the goal that is set: Decision making by the leadership team is based on consensus and is communicated effectively to all program staff. If conflict arises, it is dealt with in a mature manner, not used to sow discord. Program goals are specific, measurable, attainable, relevant, and time-bound (SMART), and decisions are assessed periodically to ensure they are supporting achievement of these goals. In addition, the leadership team ensures that all staff members understand how they can contribute to accomplishing program goals.
4. Measure engagement of staff in their roles to ensure that contributions are recognized and achieved: Standard job descriptions are available so that managers can coach staff, provide feedback in the moment, and encourage staff to be customer focused and team oriented. Time is allocated for team-building exercises. Staff are knowledgeable about the program’s vision and goals and how to accomplish those goals.
5. Participate as an academic leadership team in the Quadruple Aim: Even though the program director (PD) may not have direct responsibility for clinical practice, they must ensure clinic leadership is aligned with the ACGME required educational goals for population-based health, patient safety, quality improvement, and patient experience.
6. Build academic improvement activities into the DNA of the residency program: Schedule time for the program’s faculty, residents, and staff to participate in these activities.
7. Ensure a strong link between the family medicine residency program, the sponsoring and collaborating organization(s), and key external stakeholders: Regularly convene an advisory board that includes patients and supports the program. This can be an expanded role for the ACGME-required family medicine practice patient advisory committee, or it can be an addition that includes a fuller scope of the residency beyond its continuity clinic.
8. Ensure adequate resources to achieve the program’s strategic vision: Provide adequate, well-designed space for both the educational and clinical needs of the program.
9. Create leadership and development activities for faculty, residents, and
   staff with adequate protected time: Facilitate development opportunities (i.e., skill training) that are available to faculty and staff, including training on diversity, equity, and inclusion (DEI).
10. Model self-care as a leadership team and provide self-care education for faculty, residents, and staff: Focus on mindfulness, wellness, stress reduction, and resilience to reduce burnout and moral injury.