Introduction 

Resident doctors’ frontline experience makes them uniquely positioned to shape the future of healthcare. Despite working under unprecedented clinical pressures, they are required to conduct QI initiatives which are essential for GMC revalidation and career progression. With QI methodology rarely taught in undergraduate medical curricula, are we setting up our doctors of the future to fail? 

Currently, resident doctors lack opportunity, training and resources to create significant and long-lasting improvements. There is no unified or co-ordinated approach to QI for resident doctors, or alignment of initiatives with organisational objectives. This often leads to small-scale, “tick-box” projects which have little trust-wide significance or longevity, generating an overall feeling of dissatisfaction with the QI process. QI is frequently seen as a burdensome task which takes valuable time away from dealing with clinical priorities. 

This initiative explores how harnessing the potential of resident doctors through effective leadership and support from the chief registrar can engage resident doctors to transform that perception into one of satisfaction and commitment to the QI process, empowering them to make impactful and sustainable change within the NHS. The chief registrar programme is a national leadership scheme run by the Royal College of Physicians, which provides the opportunity for senior resident doctors who are committed to quality improvement to develop the skills of senior leaders. 

The leadership approach 

By establishing a visible and accessible leader, a co-ordinated approach to QI for resident doctors was developed at a single centre by facilitating access to improvement methodology training and developing a catalogue of projects aligned with the strategic objectives of the trust. 

According to questionnaire and focus group data, most resident doctors had never had formal QI training, and of those who had, the quality was variable. The most valuable incentives identified for engagement with QI were high-quality methodology training and motivated, trained and enthusiastic project supervisors or leaders. Barriers included lack of protected time and frequent rotation into different trusts and departments, meaning making changes often felt futile as they would not be sustained. These insights were used to inform the framework for co-ordinating QI projects for resident doctors. 

Implementation and management

Resident doctors were supported to form QI teams and were matched with priority aligned projects and supervisors. Trained improvement coaches were assigned to each team to support with QI methodology and tools, and project leaders were selected according to experience and enthusiasm. 

This approach was facilitated at a single signup event to give each participant equal and fair opportunity. Projects were closely monitored to ensure progress was maintained. The trust’s continuous improvement team was engaged to modify the QI training on offer, which was made more relevant and accessible to resident doctors. 

Outcomes and impact 

Results from the first cycle showed an increase from 37.5% completed projects in 2023-2024 (n=8) to 71% in 2024-2025 (n=14). 30 resident doctors were signed up to the initiative. All completed projects were presented locally, 4 at national conferences and 1 was published in a medical journal. 

The results made significant progress towards trust goals. One project demonstrated a projected annual cost-saving of over £5,000 through reduction of unnecessary liver function tests, and another reduced complaints relating to uDNACPR conversations by 63%. A third reduced readmission rates of patients presenting with adverse effects of antihypertensive therapy by 13% by increasing awareness of deprescribing unnecessary medication in the frail and elderly population. 

These outcomes demonstrate the substantial difference that resident doctors can make to patient safety, patient experience, cost-saving and environmental impact of the NHS when projects are co-ordinated and supported through effective leadership. This evidence will be used for a business case to employ a ‘Quality Improvement Fellow’ to ensure the initiative is maintained and sustain further progress. 

Early results for the 2025-2026 cohort look even stronger, with significant improvements having been made to the process. By using the influence of the chief registrar role and providing a regular ‘check-in’ service to help remove barriers and aid progress, momentum is maintained, and projects are much more likely to be completed. There are currently 17 projects up and running, with 52 resident doctors signed up and 11 dedicated improvement coaches assigned to support specific projects. Progress is being closely monitored, and all projects are currently on-track for completion by trust’s QI celebration event in April 2026. 

Resident doctor feedback will be gathered towards the end of this academic year to gather further qualitative data on whether this process has improved overall satisfaction with the QI process and if projects have felt meaningful, impactful and worthwhile. 

Reflections and lessons learned

The role of a transformational leader to inspire and empower teams has been fundamental to the success of this initiative. By being the driving force for change, providing direction and focus, and unblocking barriers to aid teams’ successes, future leaders can use this approach to help build a safer and more effective NHS. 

The balance between giving colleagues autonomy to work independently, providing adequate support, and promoting accountability has been challenging to navigate. It has been clear from the second cohort of projects that a more hands-on approach where teams are guided through the process and given soft deadlines has been significant in furthering progress. This reflects the significant workload and clinical pressure that resident doctors work under, which impacts motivation for QI work and is unlikely to change in the coming years. For this reason, it is imperative that investment in leadership roles for resident doctors is prioritised for continued progress and to maximise the potential of the medical workforce. 

Conclusion 

Enabling resident doctors to complete meaningful QI through effective leadership is an ideal opportunity for trusts to make significant headway towards strategic organisational objectives. The material advantages of this approach include improved patient safety and patient experience, substantial cost-savings and increased resident doctor engagement with the QI process. Continued investment in leadership roles will sustain the momentum of embedding QI into medical culture and will see its benefits amplify over time.

Author

Nicola Johnstone

Nicola is the current RCP chief registrar for Mid Cheshire Hospitals NHS Foundation Trust (2024-2026) and the peer representative for the NHS England 10-point plan to improve resident doctors’ working lives. She has completed internal medical training, MRCP (UK) and currently works as a specialty doctor in palliative care. Nicola has a strong interest in enabling resident doctors to develop their leadership potential and is a core member of the RCP resident doctors’ improvement group.

Declaration of Interests:

I have read and understood the BMJ Group policy on declaration of interests and declare the following interests: None.