Adequately resourcing administrative staff

Lois Margaret Nora, MD, JD, MBA

When a former colleague and I had lunch recently, we began discussing an issue that has long challenged medical education leaders: Insufficient administrative support. As my colleague discussed her own perspective at a business organization, I recognized that this issue is widespread and has consequences for the quality of our work and for the well-being of our teams.

Skilled support personnel such as office reception staff and administrative assistants are critical to the function of any leadership team. It’s difficult to overstate the importance of their assistance with scheduling, planning, document preparation, and representation of the team within and beyond the institution.  These individuals can also be a wonderful source of advice and institutional knowledge, and they may offer a safe space for discussion of and counsel on sensitive issues. Such professionals serve a pivotal role in identifying issues that need to be addressed, getting work done well and on time, and networking across the institution.

While it may be appropriate for administrative support professionals to function as a shared support system for a team, I have noticed that administrative support professionals are increasingly assigned to multiple senior leaders who have significant responsibility in an organization. In recent years, there has been a dramatic expansion in many schools of career advising, academic advising, and CQI functions, all of which require administrative support systems. While these changes appropriately include new decanal staff, I am not convinced there has been a consistent and commensurate expansion of support staff.  

A few consequences can result.  Administrative support professionals who answer to multiple leaders may be forced to prioritize among those they assist, setting the team up for possible conflict when time is short and deadlines are approaching. Overworked administrative professionals may struggle to maintain the quality of their work, hurting perceptions of customer service, not to mention the outcomes of the work itself.

These issues can also contribute to a sense of isolation and difficulty taking time off, creating a potent well-being challenge for administrative support personnel. The whole team inevitably feels the strain.  Others on the team may have to set aside work that only they can do to meet administrative needs, adding to inefficiency across the office.  It’s difficult for senior leaders to be as effective as possible if they are frequently pulled into administrative tasks that do not require their expertise, and their well-being may suffer, as well.

Blending my medical education accreditation work with my role as a change-maker coach for the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience, I have been working to identify intersections between well-being and accreditation. While the LCME does not explicitly set requirements for administrative support staffing, Element 2.4 sets an expectation that staffing will be adequate for supporting the mission of the school. In addition, the LCME expects offices such as Medical Education and Student Affairs to be accessible and for those professionals to be aware of and responsive to student concerns.  In my experience, student dissatisfaction often relates to limited administrative support and/or rapid turnover in staff, rather than any lack of diligence or caring among the people in those offices.

For the health of the team as well as optimal accreditation outcomes, I advise professionals to spend some time examining their administrative support staffing levels to ensure adequacy. Questions that may help stimulate this discussion include:   

• Has your team’s workload grown? Consider how your class size and/or program load compares with 10 years ago.

• Has the size of your support staff grown concurrently with the expansion of middle management?

• Have people been promoted to middle management without shedding their administrative support roles? Internal development and promotion are things to celebrate, but some new managers may need additional support to meet the expectations of their new jobs.

• Are people across your team working at the top of their expertise, or are they handling tasks that take time away from their most important work?

• Are there staffing guidelines available for your area of work? Some organizations, such as the National Association of Student Financial Aid Administrators, set benchmarks for staffing that may be helpful. When considering such benchmarks, keep in mind that issues faced by medical and other graduate students can have unique complexities that may influence staffing needs.

• Review your results from the AAMC GQ and any annual student surveys your school is conducting. If you are maintaining your DCI regularly as we have suggested, you can start by reviewing the latest information there. If scores related to the availability and responsiveness of staff in areas like career counseling, academic advising, and financial services suggest there are problems, consider whether the teams in those offices are overextended and could benefit from enhanced administrative support.

Hopefully, these conversations will spark meaningful ideas for supporting your full team and the work they do. These discussions will also likely inspire ideas for supporting administrative support professionals themselves. Here are five that I think are particularly important:

• Ensure adequate staffing: As discussed above, inadequate administrative support staffing puts a strain on everyone, particularly administrative support professionals themselves. These colleagues often manage entry points to our offices; if they cannot function effectively, we can expect concerns about accessibility.

• Keep an eye on compensation: It’s worth looking at benchmarks for salaries across your team, especially as workloads expand. Administrative support professionals who have not received promotion-related compensation changes may warrant particular attention. Make sure pay reflects the value these professionals bring to the team and the school.

• Engage the full team in planning: The institutional knowledge and perspectives of administrative support professionals bring unique value to goal setting and strategic planning. Meaningful inclusion of these professionals in such processes is critical to maximizing results.

• Encourage professional development: Growth is not just about promotion. Ensure your administrative support staff has access to professional development opportunities — and your full support for taking time away from day-to-day work for these activities. The whole team will benefit from this investment in professional skills and satisfaction.  

• Celebrate your team: Recognizing contributions across the team is a tenet of good leadership. Be sure your administrative support staff has the same opportunities as others to celebrate your office’s achievements, and be sure to acknowledge the great work these professionals do every day.

It’s not difficult to imagine how administrative support professionals become overloaded with work. The most skilled of these professionals make balancing many complex tasks and priorities look easy. However, real problems can result when these colleagues are stretched too thin. As accreditation professionals work to address problems that may link to the effectiveness of senior leaders, ensuring staffing adequacy and appropriate attention to the needs of administrative support professionals may be a helpful place to start.

Leadership lessons from WFME’s past president

Lois Margaret Nora, MD, JD, MBA

I have been interested in leadership since the start of my career, and over the years, other leaders have been some of my most valuable teachers.  Dr. David Gordon, who recently completed his term as president of the World Federation of Medical Education (WFME, Federation), is one of those teachers. 

WFME has played an important leadership role in issues related to medical education since it was organized in 1972.  However, its importance in global education increased dramatically in the wake of a 2010 Education Commission on Foreign Medical Graduates (ECFMG) decision emphasizing the importance of medical school quality around the world and announcing plans to ultimately limit ECFMG certification to graduates of medical schools with accreditation from authorities recognized by the ECFMG. WFME responded by creating a system for recognition of accrediting agencies, by evaluating them against criteria for accreditation and promoting continuous quality improvement.  The criteria were based on standards for accreditation agreed upon at a WHO-WFME meeting in 2005. The Federation was already known for its standards for medical education at the undergraduate, graduate, and post-graduate levels, first published in 2003.

As a medical educator and voluntary assessor with WFME, I’ve seen the impact of WFME’s leadership on quality in medical education. Dr. Gordon has been a driving force behind this work.

When I learned that this important leader was retiring from the WFME presidency, I was delighted to have a chance to speak with him. Dr. Gordon generously shared thoughts on his career, his work at WFME, and the work at the Federation of which he is most proud. 

Lessons from a former medical school dean

Prior to joining and ultimately taking the helm of WFME, Dr. Gordon served as dean of the medical faculty at the University of Manchester, chair of the Council of Heads of Medical Schools of the UK, and President of the Association of Medical Schools in Europe, among other roles. As he spoke with me about his progress though roles with increasing administrative responsibilities, it became clear to me that these experiences — and Dr. Gordon’s experiences as dean in particular — provided exposure to the systems and operational perspectives needed to evolve WFME’s constitution, internal processes, and role in the global medical education community. In fact, the competencies that position medical school deans to succeed were a theme throughout our conversation.

Established by the World Medical Association and the World Health Organization, the Federation works with executive council members and partners in medical education, all of which have important roles in quality higher education, research, and professional medicine. Much like a medical school dean, Dr. Gordon could only deliver on his organizational mission by working to support the success of these and other agencies, such as the Foundation for Advancement of International Medical Education and Research (FAIMER), the International Federation of Medical Students’ Associations (IFMSA), and the Association for Medical Education in Europe (AMEE).

Support for quality and standards in medical education is a central focus of WFME’s work. However, it’s difficult to overstate the complexity of such work on a global scale. It requires a framework with relevance across cultures and medical education systems — regardless of their sophistication and resources — and the skills to work effectively with diverse groups of stakeholders.  As we talked, it became clear to me that Dr. Gordon drew on not just his own experience as he sought to build out this framework, but also on legislative leadership capabilities and a clear understanding of systems thinking, the same skills a medical school dean uses to achieve her mission.

Continuous quality improvement as common ground

A systems-thinking mindset may also explain how WFME has been able to not only manage partnerships with a variety of stakeholders, but also to leverage those same partnerships to deliver on a global mission. For example, WFME works with FAIMER to maintain the World Directory of Medical Schools, a listing of more than 3,750 undergraduate medical education programs. The collaboration unified two separate directories, streamlining data submissions for schools. The result is an integrated resource that meets needs around the world.

As I listened to Dr. Gordon talk about this work, I was reminded that standards and quality in medical education provide common ground for many stakeholders around the world, regardless of their role in healthcare and health professions education. Dr. Gordon’s ability to make the most of this common ground may explain much of his success in support of quality and continuous quality improvement in medical education. 

Relationships and people make the difference

While it’s clear that Dr. Gordon brings the skillset and mindset needed to lead a complicated organization and mission, he continually credited the relationships he formed and the people he worked with for his success. In fact, when I asked him what he’s most proud of, he said it’s his team.

“It’s very satisfying to see people you’ve worked with, and helped, doing really well,” he said.

Having received some of my most important mentoring from WFME staff, I can see what he means. It’s hard to overstate the complexity of building an international team of staff and volunteers that work as seamlessly as WFME’s teams do across international lines. While this success is a credit to many people on WFME’s staff of skilled professionals, it also speaks to leadership. 

My congratulations to Dr. David Gordon on the great work WFME has done on his watch. I am delighted to hear that he will remain in an advisory role with the Federation, which is a duty of the past president under WFME’s constitution. And congratulations as well to new WFME President Ricardo León-Bórquez and his team. I look forward to seeing what’s next for WFME, WFME’s new leadership, and Dr. Gordon himself.

How one physician is making the most of overnight medical education

Lois Margaret Nora, MD, JD, MBA

In medical school, I experienced some of my favorite and least-favorite experiences during overnight call.  And I have been dismayed at the substantial reduction in overnight experiences that more recent generations of medical students have had. So, I was excited to hear about some particularly interesting work by Dr. Jessica Chambers of Dell Medical School at the University of Texas at Austin. I was delighted to have time to talk and to learn more about her career and how she’s made the overnight rotation much more than something to simply endure. The following post is a synopsis of our conversation.

Dr. Chambers attended medical school at Texas A&M University before pursuing residency at UT. Now a practicing nocturnist and assistant professor of internal medicine, she’s been working to transform learning in the overnight hours. As we spoke, it became clear that she’s done so through a combination of passion and leadership.

Anyone who has worked overnight call knows the hospital environment is quite different at night. There are fewer patients and visitors coming and going, and the staff is smaller. Certain issues are more common in the evening, fewer specialists are available, and there is reduced access to hospital services, such as some types of imaging and surgery. However, Dr. Chambers says that’s also part of what makes overnight medicine so beneficial to learners: “I think your decision-making and triage skills are different than those developed in the daytime.”

Medical students and residents on the night rotation are part of small, highly interprofessional teams, giving them valuable experience communicating and collaborating with colleagues, and valuable exposure to team-based care. Dr. Chambers says overnight teams also spend more time on functions like admission and bedside management, enabling learners to interact with patients in a more holistic way. “We get to understand the perspective of the nursing staff, what the charge nurse does, the interplay with the respiratory therapists and the social worker in the ER. Instead of focusing on how to get the patient out of the hospital, we’re really focused on how to best take care of the patient in the hospital,” she says.  “That, I think, is why I found this niche. It’s such an ideal time for education because we often don’t have other things we have to focus on.”

A dedicated curriculum for the overnight rotation

The overnight medicine curriculum Dr. Chambers developed came out of early bedside talks she gave while working with residents. As common issues like shortness of breath, chest pain, headache – “very rote things, but out of them comes a lot of medicine” – became favorite lecture topics among residents, it became clear to Dr. Chambers that there was value in developing a defined list of areas that should be covered on the overnight rotation. Some arise organically in a hospital where the overnight team can be responsible for well over 100 internal medicine patients, and others can be worked in as short lectures during downtime.

About six months into her first faculty role as a nocturnist, Dr. Chambers recognized opportunities for a more structured approach to educating learners on the overnight shift before they reached residency. “I thought, wouldn’t it be great if you had practice doing this as a fourth-year medical student, because this was the scariest rotation I had as an intern.” She went on to establish an elective with a reasonable schedule – 11 p.m. to 7 a.m., four nights a week – to entice students who might be reluctant to try something more time-intensive. “This is not about overloading them with patient care; this is very particular to how to cross-cover patients at night,” she said.

As Dr. Chambers built out her course objectives, she saw an opportunity to help students and residents build communication skills. Overnight medicine provides more opportunity for connection with patients, who may feel especially vulnerable and alone after visitors leave. Clinicians often find they have more time for bedside conversations, where they can enhance their understanding not only of a patient’s medical condition, but also the patient experience. While these skills are important for nocturnists, they are valuable for any clinician.  

Dr. Chambers also asks learners to build skills for working with the care team, and I was especially intrigued by the way she approaches this teaching with fourth-year medical students who take part in her elective rotation. Students are asked to be the point of contact for a subset of patients, meaning they gain experience talking with nurses, pharmacists, and respiratory therapists; entering orders into the EMR; and making decisions about care.

The work is guided – a qualified physician is always present when a medical student is answering pages or replying to messages from the care team, and any order placed in the EMR by a student needs to be activated by a physician. But she encourages students to draw conclusions and also to ask questions when they are unsure of next steps. Modeling behavior helps; Dr. Chambers herself invites input from residents in the presence of medical students before making decisions, demonstrating to students that the nocturnist must have knowledge of many specialties but simply can’t be expert in everything. “They have to really embrace that level of not knowing, which is something we see every night.”

To that end, Dr. Chambers has also developed a Night Medicine Guide that draws on the expertise of her colleagues in other specialties. Listening to her describe the collaboration involved with creating the resource, I was impressed with her leadership in bringing multiple stakeholders together to develop this valuable resource.

The Night Medicine Guide reflects the guidelines of specialty medicine and outlines protocols for scenarios that can be handled by the overnight team, as well as scenarios that warrant a call to the attending physician. “A lot of the fright of doing a night shift is, when do I call cardiology? Should I call the GI doctor? Am I taking good care of this patient? Am I doing the standard of care at 2 a.m.?” she said. A grant from the medical school ensures every learner gets a copy of the guide.  

I remember from my own days on the overnight rotation, one of the more challenging scenarios is trying to navigate the line between clinical issues you can handle and those that warrant a call to another specialist. It is a gray area that can be stressful and a source of conflict. As I thought about this, I wondered if Dr. Chambers’ guide might also be a useful tool for supporting clinician well-being. The clarity it provides for handling situations like pain, delirium, suicide risk, and others strikes me as reassuring and empowering for clinicians across the healthcare team.

A culture change for overnight medicine

Talking to Dr. Chambers was particularly interesting as I thought about how overnight rotations have been commonly perceived. Although it’s easy to understand that patients have needs around the clock, persuading others to see the unique value in learning at 2 a.m. seems less easy. It’s clear that leveraging the learning opportunity as Dr. Chambers has done has required a shift in perceptions about overnight medicine.

That change has taken time, Dr. Chambers says, and since she cannot work every night, it has also taken advocacy and leadership to shift views about how learners and clinicians can make the most of the overnight rotation. It has also taken work on her part to foster a positive team culture. Things like shared meals build community. And open conversation about what’s important to stay healthy while working overnight normalizes challenges and helps colleagues – particularly those who are still getting accustomed to the schedule. She is also a strong advocate for reasonable hours that allow for, for example, dinner with family before a shift begins. “I think that connection time is very important; it’s what leads to me loving this job. I don’t go to work missing my family more than I would any other job.”

While I knew I would learn from Dr. Chambers about the possibilities of learning as part of overnight medicine, I also learned some things I didn’t know about the health effects of night work.  Resisting the body’s natural sleep cycle alone is challenging enough, but Dr. Chambers noted that overnight work is linked with poor eating habits, weight gain, metabolic syndrome, breast cancer, and potentially fertility issues.  She also said the life of a nocturnist is likely not a good fit for people who do not sleep easily.  It’s important, too, that nocturnists have a supportive home environment to facilitate daytime sleep, and a supportive working environment that includes scheduling important meetings at a reasonable time for someone who must sleep during the day.

I was thrilled to learn that Dr. Chambers is working as part of organized medicine to lead change beyond her institution. She has what sounds like an interesting talk planned at an upcoming meeting of the Society of Hospital Medicine about managing the health consequences of overnight medicine, and she’s been active with a number of other societies.  Her efforts to reimagine overnight education and the culture of the overnight shift have also helped her find a growing community of like-minded physicians who have been on the forefront of changing perceptions of nocturnal medicine and seizing its unique learning opportunities. “You could obviously do this job very easily, but to do it well, to make sure the academic opportunities are very useful, you have to put in more time. However, I find it very easy if you love what you do, which I do. I love what I do.”

Quieting noise: An opportunity to support great accreditation decisions

Lois Margaret Nora, MD, JD, MBA

I recently finished the book Noise, by Daniel Kahneman, Olivier Sibony, and Cass R. Sunstein.  While I generally agree with reviewer Caroline Criado Perez that this book was longer than necessary, the title of her piece, The Price of Poor Judgement, is apt. The book builds upon the authors’ prior work on improving decisions and sheds light on how a better understanding of what they call “noise” can help us evaluate and improve upon our decision-making.

The authors of Noise describe a body of evidence illustrating that circumstances having nothing to do with the choice at hand — from weather to the time of day to the performance of the local sports team — can influence the judgements we make.  The result can be substantial inconsistency among decisions involving similar or even nearly identical scenarios.  The authors cite evidence from criminal sentencing, hiring, foreign policy, business planning, and medicine, making the case that noise is far more pervasive than most of us realize, and that people and organizations should strive to manage noise to improve decision-making of all types.  While the book doesn’t discuss accreditation decisions, it is worth thinking about how noise and efforts to mitigate it might influence these processes.  

Many programs and institutions — including universities, hospitals, certifying organizations, and professional education programs (medicine, law, allied health) participate in accreditation programs.   Accreditation status is important to eligibility for federal funding, national rankings, attracting students, and maintaining public trust.  The stakes associated with these decisions are high, and the resources necessary to achieve and maintain accredited status are substantial.  While accreditation organizations make substantial efforts to ensure that their judgements are consistent and fair, specific attention to the issue of noise may be helpful.

Understanding noise

It’s reasonable to expect that similar circumstances will result in similar decisions.  However, that is not always the case – in fact, it is often not the case.  Using target-shooting as a metaphor, the authors note that multiple hits at the center of a target would be representative of consistent decisions involving minimal error.  Bias, which the authors distinguish from noise, would be represented by multiple shots that miss the center of the target, landing instead in a cluster to one side.  And noise is represented by a scattershot pattern: The shots are distributed in a random fashion across the target.  You will find a helpful visual in this HBR piece.

In practice, the scattershot scenario represents myriad conclusions, all different from one another for no obvious reason.  If the facts in a particular situation – criminal sentencing or hiring or accreditation – are similar, the decisions should generally also be similar. And yet, the authors present compelling evidence that such inconsistency in decision-making can occur at the individual level (when a person’s conclusions vary across multiple similar scenarios) and in group decisions (concerning a single case or multiple cases over time).  The variables associated with this inconsistency are unrelated to the circumstances of the decisions themselves. Examples include hunger, time of day, mood, and weather on the individual level and group dynamics and communication norms at the team level.   

To combat these influences, the authors urge individuals and organizations to prioritize what they call decision hygiene – a collection of tools and tactics intended to mitigate the effects of noise and otherwise improve decision-making. It is important to note that decision hygiene does not mean removing discretion from decision-making. In medicine, for example, even if two people present with similar symptoms and medical history, there may be important differences between their circumstances and preferences that are worth considering, and it may be appropriate for a healthcare professional to recommend different treatment plans to them as a result. 

Rather, the authors note, many of our heuristics or patterns of thinking — including relying on gut feelings, substituting easier questions for harder ones, halo effects, prejudgment, confirmation bias, and overconfidence — can contribute to noise.  Fortunately, it’s possible to mitigate these influences and improve our decision-making.

Assessing and minimizing noise in the context of accreditation

Accreditation decisions are complex.  Accreditors with organizations such as the Liaison Committee on Medical Education, the Southern Association of Colleges and Schools, the Joint Commission, and the National Commission for Certifying Agencies must assess compliance against many standards and elements. In many cases, those decisions draw on evidence from thousands of pages of documentation as well as site visits that can involve a week’s worth of meetings. Many perspectives are involved, including those of site visitors, staff, and committee decision-makers.

Recognizing the complexity of this work, accrediting bodies place great emphasis on bringing validated and trustworthy processes to their decisions. Throughout my own career, I have seen firsthand the efforts made by accreditation committees and staff members to ensure a consistent, fair process with integrity. Everyone involved, particularly accreditors themselves, wants these decisions to be the best they can be. Learning about and taking steps (or augmenting existing tactics) to mitigate risk of noise may be a worthwhile part of this work.

Building from the authors’ recommendations, here are some thoughts about how people involved with accreditation can work to mitigate the effects of noise in their own decision-making as well as when working as part of a team. It may be useful to think about these efforts in two buckets: prior to decisions (general efforts to understand and manage noise) and then during decision-making (procedural adjustments that may help).   

Prior to decision-making:

1.       Introduce the concept of noise. Because accreditation site visit teams and committees bring together people with diverse experiences and viewpoints, a discussion about best practices for decision-making is reasonable and expected. Orientations for individuals and groups working in accreditation provide an excellent opportunity to introduce the concept of noise. Simply learning about noise is powerful, and individuals who are exposed to the concept may proactively modify their own approach to decision-making in an effort to reduce the effect of noise.

2.       Make reducing noise and improving decision-making themes for professional development.  Consider gathering teams ahead of a site visit or program review for dedicated professional development on these topics. Scenario reviews can provide opportunities for discussion of how individuals arrive at their decisions and how groups can more effectively make decisions.  Teams can discuss how to promote expression of a variety of perspectives and explore ways of reducing noise.  Guidelines, structuring complex judgements, and deliberately incorporating counter-arguments are techniques that may warrant particular attention.  

3.       Conduct a noise audit.  Although it can be challenging to systematically examine the quality of judgments made by a group of people, noise audits involving hypothetical scenarios generate valuable information.  The process can help quantify whether noise is in fact affecting decision-making and to what extent, providing a data foundation for making improvements.  Although noise audits often involve external consultants, the expertise within accrediting organizations may mean they have resources that could allow for a thoughtful audit by an internal team.

During decision-making:

1.       Meet the group’s human needs.  Reducing noise in group decision-making begins with planning the meeting. Considering of time of day, scheduling regular breaks, and providing drinks and snacks that include protein will go a long way toward ensuring everyone is at their best. This kind of preparation ensures participants have what they need to act on their own awareness of noise — those who understand that hunger or fatigue, for example, may influence their decisions know they simply need to get a snack or take a break to improve their work.

2.       Ensure all perspectives are heard.  Use words and actions to demonstrate that alternate opinions will be welcome and listened to. Polling apps that allow people to register their opinions prior to discussion may also help ensure more perspectives are considered more fully before conclusions are drawn.  One tool we have used with success is Poll Everywhere, though there are many to choose from.

3.       Leverage decision hygiene practices. Using decision guidelines can reduce inconsistency among decision-makers by providing clarity around what constitutes acceptable performance and how to assess and weight various measures of compliance. Dividing complex decisions into component parts can reduce the likelihood that performance in one area influences perception of performance in other areas. And rotating the order in which people speak can help ensure all participants have an opportunity to influence the discussion.

4.       Actively monitor for noise. Consider tasking an independent person with watching for and speaking up as they see things that could be noise, and be sure to engage others in welcoming and legitimizing the feedback.  Questions like those listed in the bias observation checklist included in Noise may also help.

Supporting quality in all we do

Decisions are an important part of life, and we all have a stake in ensuring they are the best they can be. Practices to mitigate noise hold promise for enhancing accuracy and consistency in our own decision-making and in decisions made by groups of all types, including those involved with accreditation.