The role of the Chief Registrar in the Future Hospital:

? Leaders for today or tomorrow ?

Dr Jamie Kitt1 and Dr Mridula Rajwani2

1Cardiology & GIM ST6 and Chief Registrar 2Acute & General Internal Medicine ST7 and Chief Registrar

1Frimley Health NHSFT 2 Oxford University Hospitals NHSFT

What is a ‘Chief Registrar’?

• RCP pilot – ‘fellowship’ in leadership and management- whilst remaining in clinical practice. Senior medical registrar: credibility.

• 60% clinical vs. 40% non-clinical (Flexible)

• We are both in first cohort through the pilot

Management and

Leadership

Research

Teaching

Clinical

The programme offers wide scope

– Service redesign/Business case formulation

– Quality improvement

– Junior doctor engagement

– Patient safety

– Teaching and training

– Insight into clinical leadership roles

What have we been doing?

1. Service improvement

Main problem facing most trusts = patient flow:

- ED/A&E to Medicine

- GP to Medicine

- (Medicine to social/community care)

Other key trust wide issues are:

1. Junior doctor morale

2. Training versus service provision

3. Communication gap between senior management and those on the shop floor.

The ‘Problem’ with flow at Wexham Park

• Under-utilisation of Ambulatory care

• Poor communication between ED and Medicine

– Electronic referral system

• Lack of triage of GP referrals to the appropriate stream

Starting point at Wexham Park

% of the take admitted VIA GP

% of take sent to AECU

ED to Medicine conversion rate

% admission avoided via phone

Disposal rate from A&E (%)

55.3% 25.0% 45.0 2.0 1.0

0.0

10.0

20.0

30.0

40.0

50.0

60.0

% of the take admittedVIA GP

% of take sent to AECU ED to Medicine conversionrate

% admission avoidance viatelephone triage

Disposal rate fromA &E

Baseline Data for flow around the acute medical take

What we have done to help flow

• Stakeholder engagement = Key

• Unified single clerking proforma

• Serial pilot programmes using QIP methodology to address each aspect of flow:

a) Expansion of ambulatory care– Chief SpR clinical support/new pathways for referral

b) GP referral & triage pilot study

c) ED to Medicine referral redesign

GP call to 07833481742 (AECU mobile) answered by

medical SpR & History + examination findings +

Observations discussed

If Clinically Stable

NEWS at GP<2

(Observations stable)

‘Ambulatory’ patient

Clinical condition

suitable for ambulatory

assessment (see

below)

N.B. SpR MUST takes

NEWS score, Name, DOB &

NHS/Hospital # to pass to

administrative team in ED

hub and tell them to put

under AMBULATORY CARE

Unstable clinically

– Advise GP to send by

ambulance directly to A&E

SpR MUST takes NEWS score,

Name, DOB & NHS/Hospital # to

pass to administrative team in ED

hub for patient to be ‘added’ to

expected medical take list

If clinical acuity based on

GP assessment is unclear

then:

1. Advise to send to A&E

purple zone

2. Medical SpR to assess

in purple for focused

Hx, examination, VBG

+/- ECG

ADMIT DIRECTLY ONTO

acute medical take list and

keep patient in A&E

FURTHER ASSESSMENT

IN AMBULATORY CARE

(AECU)- CALL 4237/4782)

‘UNWELL’ Clinically ‘Well’

Call AECU to discuss transfer

Ambulatory ‘suitable’ conditions:

- Headache ( Not ? SAH/meningitis)

- DVT + Low risk PE

- Low Risk TnT- ve Chest Pain

- Stable cellulitis

- Stable pyelonephritis/MDR UTI

- Stable Community acquire pneumonia

- Stable Pleural effusions (Friday AM on AECU pleural drainage list)

- Low risk Syncope

- ‘Well’ PUO/Fever in returning traveller

- Mild exacerbations of asthma/COPD

- Mildly deranged Na+/Calcium etc

Rapid access pathways

available at Wexham:

- Suspected angina clinic (<10

working days) (form on ICE)

- Rapid access syncope clinic - <2/52

(form on ICE)

- Neurology referral – urgent clinic

within 2 weeks (form on ICE)

DIRECTLY HOME FROM

BLUE ZONE AFTER

RESULTS REVIEWED WITH

URGENT OP F/UP

N.B. If you’re unclear where to

manage a patient please D/W

Medical Consultant in ED or

AECU for advice

Appendix 1: Pilot Pathway for GP Referrals via Medical SpR

GP referral pilot

Streamlined AECU referral pathways

Impact of Serial Pilots on patient flow

Feedback and development areas

• Patient and family : Positive

• Communication barriers : between ED and AECU and AMU – Human factors…

• Sustaining the pilot successes in the long run

– Matron AECU: Sean Harding- MA project on service optimisation

– Change in consultant job plans….

CR-

CR+ Difference (95% CI)

P-value

Patients in AEC/day (SD)

15 (4)

23 (4)

8 (4 -11)

<0.01

%Medical take in AEC (SD)

23.6 (6.5)

27.6 (7.0)

4 (0.3 - 11.7)

0.04

%GP calls triaged away fro ED to clinic or AECU (SD)

20.4 (12.2)

32.6 (9.3)

12 (2.7 - 21.8)

0.01

% Conversion of ED patients referred to Medicine

40% 25% 15% <0.01

2. Personal and Professional Development as a ‘future

leader’

Oxford University Hospitals NHS Trust

• 2 chief registrars – primarily for Ambulatory Care (New Unit)

• Mridula Rajwani- ST7 Acute Medicine Trainee

• Judy Martin – ST6 Geriatric Medicine Trainee

Chief Registrar Education & Development

• Combined educational and mentoring programme by the RCP and the FMLM

• Modules on Team building , Change

Management, Quality Improvement, Data Analysis and SPC, Emotional intelligence + Medical leadership

• Peer-Peer Support

Professional Development

MENTOR (s)

Monthly Chief Registrar Meetings

Educational Supervisor-

Research Background

Attendance at Divisional meetings –

clinical service &

flow

Peer Feedback- ACTION LEARNING EXERCISE

‘Clinical time’ on

Ambulatory Unit

Personal Development • Shaping the role & identity of the Chief Registrar

• Interacting with leadership (clinical and non-clincal) & NHS improvement

• Learning about trust pressures, leadership roles and stakeholders

• Planning non-clinical time- Very busy!

• Managing meetings & leading teams

• Engagement/Supervising in Quality Improvement

• Change management – CULTURE change takes time- engagement, feedback, PDSA cycles.

Quality Improvement Projects at OUH

Hospital at night handover AIM

registrars

AGM Clinical Lead

Core Medical Trainees

Morning Handover in

AGM

AGM Clinical Lead

AIM Registrar

FY1 doctor

Interface with radiology and ambulatory

care

FY2

Consultant AGM

Consultant Radiology

Consultant Respiratory

Radiographers -Superintendent

Admin team

Interface with acute oncology and ambulatory

AOS Nurse Specialist

AOS Clinical Lead

Oncology Matron

AOS Consultants

AAU Consultant Lead

Rapid Nursing Assessment on

AAU

Core Medical Trainee

AAU Clinical Lead

Ward Manager AAU

3. Relationships and junior doctor support

Supporting colleagues • Establishing monthly Registrar and CMT

Forums with Clinical Leads

• Sitting on Consultant Forum monthly

• Interface with other specialties

– Radiology, Acute Oncology, Heart Failure, Respiratory.

• Addressing morale: Coffee voucher scheme

• Establishing CMT and ST3-ST4 simulation based learning across Oxford Deanery

How does being a ‘Chief Registrar’ help?

• Recognition by, and mutual respect of peers

• Recognition and respect from clinical leads

• Access to data collection teams/analysts

• Access to Chiefs of service /medical director

• Chief Registrar can be a ‘change agent’

– Credible, yet non-threatening.

Challenges

• Identifying all key stakeholders (resistors!)

• Time taken to effect and evidence change using PDSA….and sustainability

• Only 1 year to achieve a lot

• Money talks!!!