22. Residency Program Committee

Introduction

An effectively structured RPC is an invaluable tool to help share the work of managing your program and to ensure your training program is fully engaged in continuous quality improvement. In contrast, a poorly functioning RPC will hinder your ability to improve or even maintain your program quality. One of the most important roles a program director plays is the development and ongoing support and nurturing of the RPC and its subcommittees. An effective RPC helps ensure your program is structured in a way to share workload, operates with a spirit of continuous quality improvement and considers impacts on all stakeholders. Effective management of the RPC requires careful consideration of what can be completed and reviewed within the RPC itself, which tasks require subcommittees and which situations may need alternate strategies such as a working group to deal with a particular problem.

Reviewing the structure of your residency program Committee

There are several key issues to consider when reviewing the structure of your RPC, including its membership and the timing and structure of its meetings. RPC meetings should not take place as an extension of regular departmental or divisional meetings. The RPC must be a stand-alone, autonomous committee. The Royal College of Physicians and Surgeons’ accreditation standards require representation from key stakeholders, including major academic and clinical components and relevant learning sites (indicator 1.2.1.1).¹ It is important that all major teaching sites are able to contribute to the administration of the program and that they receive effective communication about the program. Meetings must be well organized and have clear agendas and minutes. Meetings should be scheduled well in advance, occur regularly and not be cancelled. The frequency of meetings may vary but must be sufficient to fulfill the committee’s mandate (indicator 1.2.2.4).

Committee size

The size of the RPC size should be determined by considering what must be done to effectively manage your program. If the committee is too small, the individual members may be overburdened with work, which will probably lead to an overreliance on the program director. A committee that is too large can lead to disengagement, as members are unlikely to have a chance to contribute substantially. The “rule of seven” ^2,3 indicates that a group of seven is optimal for group decision-making and that each person added to a group beyond seven reduces the effectiveness of decision-making by 10%. Although it is probably not possible for most programs to limit the size of their RPC to seven members, especially large entry-level programs, the concept speaks to the need to keep committees as small as is reasonable, within the guidelines for membership. This concept also speaks to the fact that many tasks may be better completed by subcommittees or working groups. To keep your committee an appropriate size, it is important that your terms of reference clearly identify individual members with meaningful and well-defined roles.

Membership

By carefully structuring your RPC membership you can help ensure that it benefits from diverse representation and perspectives beyond the needs of your academic centre. For example, if your residents rotate through a community site, the site director should sit on your RPC. Having the research director sit on the RPC will help to facilitate the scholarly or research components of your program. Accreditation standards require that individuals involved in resident wellness and safety have the ability to provide input to the RPC (indicator 1.2.1.3).¹ This can be achieved by adding a wellness or safety director to the RPC or calling on existing RPC members to provide reports on these issues. In some programs, the RPC may benefit from representation from other health professionals or disciplines. For example, a surgical program may benefit from having Anesthesiology or Nursing representatives on its RPC; a Radiation Oncology program may choose to have representation from Medical Oncology or related professions like Medical Physics. Last, effective committees include members with various diverse backgrounds, such as identity or lived experiences (e.g. BIPOC, women, physicians with disabilities) or job type (e.g. academic vs non-academic). Perspectives of these individuals are key, and their participation should not be viewed as a check-box for EDI; program indicators related to EDI are more reflective of whether EDI concepts are being adequately incorporated into the program at the direction of the RPC.

Another challenge in structuring RPC membership is whether to include RPC members by virtue of other positions they may hold. Such members are referred to as ex officio members. They may include department chairs, division chairs, the associate dean, program directors from allied programs or faculty members who hold key clinical, administration or research positions. Often it can be helpful to include ex officio members to ensure diverse representation on the RPC and to aid with communication between the program and key stakeholders. Be mindful of the committee becoming too large or of adding members who may not be truly interested in the residency program. You could consider adding such individuals as corresponding (nonvoting) members or hosting them periodically as guests. For instance, some faculty members may have a special interest or responsibility related to a particular educational experience, rotation or curricular element; in these cases, you may wish to invite that faculty member to attend meetings when relevant issues are being discussed, without having them on the RPC as a full member.

Finally, resident engagement in the RPC is an absolute requirement; your residents are the end users of the program and will know the program’s strengths and weaknesses better than anyone. Accreditation standards indicate there must be “an effective, fair, and transparent process for residents to select their representatives on the residency program committee” (indicator 1.2.1.2).¹ For many programs, this means the chief resident(s) plus one or two more (depending on the size of the program) selected or elected representatives. In addition to the chief resident, additional residents must be elected by their peers and this process must be arms length from the program leadership. The number of resident representatives will vary according to the size of the program. Additional resident representatives could be determined by year, stage of training or site or to represent certain issues such as research, quality improvement, EDI or wellness. The mechanism by which residents are chosen needs to be clear so that you can demonstrate compliance with this requirement during accreditation reviews. The terms of reference should also outline the expectations of the resident members and give residents an explicit voice on the committee. The RPC should always consider feedback from the resident body on all changes and initiatives that are being discussed, and the agenda for RPC meetings should include standing reports from residents to give voice to issues and concerns that arise. Needless to say, resident members on the RPC should be full voting members, with a voice equal to that of faculty members, and should be given the respect of peers.

A common challenge is to find a way to engage faculty members who want to contribute to residency training without necessarily adding them to the RPC. Some faculty members may have been on the RPC in the past; others may wish to be added. This enthusiasm can be at odds with the desire to maintain an efficient RPC. For example, a RPC that has historically been large and inefficient may benefit from having its roles redefined and its membership reduced. This may require some members to leave the RPC. This must be handled tactfully and respectfully, to maintain enthusiasm for the program and avoid offending those who are leaving. Thank you letters (which can be included in a teaching dossier), a gift or a gathering to celebrate the contributions of departing members can be effective ways to show respect and appreciation. You may also choose to ask faculty members important to the functioning of your program to join RPC subcommittees or to fill academic advisor or other mentorship roles.

Quorum

Quorum (usually 50% plus one) should be achieved for all meetings and an explicit agenda set in advance. Attendance records should be kept, and members should be expected to attend all meetings unless regrets have been sent. An appropriately small RPC cannot afford to carry committee members who frequently miss meetings or do not contribute to the work of managing the program. Term limits are one way to ensure periodic turnover of members.

Terms of reference

In accordance with Robert’s Rules of Order,⁴ the RPC should be a “deliberative assembly” with well-defined terms of reference. This is an accreditation standard, in that each RPC must have terms of reference that are clearly written and provide a detailed description of the composition of the committee and the roles and responsibilities of each member (indicator 1.2.2.1).¹ Training programs evolve constantly, and the terms of reference should be reviewed regularly to ensure the RPC continues to meet the needs of its residents, department, community, university and the Royal College. Review of the terms of reference can be a standing item done at the beginning or end of each academic year.

When writing or revising your terms of reference, ensure the document is clear and concise. Most postgraduate medical education offices will have a template you can use as a starting point. Several templates are also available online, including some recommended in the further reading below. It can be helpful to look to similar programs at your university or nationally for ideas. The terms of reference ideally will include the following information:

• The committee’s mandate and the overall goals of the training program
• The frequency of RPC meetings
• The committee’s membership — The terms of reference should specify who is on the committee, the duration of each member’s term and whether the term is renewable.
• Quorum — This can vary, but quorum is typically 50% plus one.
• Reporting relationship and subcommittees — The terms of reference should indicate which committees report to RPC, the reporting relationship, the person or body to whom the RPC is accountable and the way in which the committee reports to that person or body (e.g., the person or people to whom minutes are distributed).
• Committee responsibilities — This may include overseeing resident assessment and selection, the continuous quality improvement process and the annual program review (what is reviewed and when).
• Responsibilities of individual committee members — It can help to be as specific as possible in defining the responsibilities for accountability purposes and to help describe what type of commitment is involved when recruiting new members.
• Decision-making structure — Decisions are often made by majority vote; however, in certain situations other methods may be more appropriate. For example, for EDI issues, minority viewpoints or suggestions may be better served using other decision-making structures, such as consensus decision-making that aims to have agreement with all members. It may be pertinent to develop an explicit way to identify what decisions may be better served by a decision-making process other than majority vote.

Subcommittees

“Which subcommittees are necessary and when is a subcommittee not required?”

Accreditation standards indicate that “the mandate of the residency program committee includes planning and organizing the residency program, including selection of residents, educational design, policy and process development, safety, resident wellness, assessment of resident progress and continuous improvement” (indicator 1.2.2.3).¹ Practically speaking, the scope of this work is beyond what can be accomplished in most regular RPC meetings or by RPC members alone.

The creation of subcommittees is an essential tool to share this work. Common subcommittees employed in successful programs include resident selection, research/scholarship, quality improvement, curriculum, simulation, EDI and wellness. The need for specific subcommittees will vary from program to program, depending on the structure of the RPC and the setting. All programs must have a competence committee (or equivalent), which is “responsible for reviewing residents’ readiness for increasing professional responsibility, promotion, and transition to practice” (indicator 1.2.2.5).¹ Most programs have a resident selection committee, although this task can be completed by the RPC or a time-limited working group struck during the selection period.

When a standing subcommittee is mounted, the same principles used for the RPC apply: the subcommittee needs to have clear Terms of reference, a clear chair (or lead) and clear membership responsibilities. Subcommittees must report to the RPC, as the RPC carries the ultimate responsibility for oversight of the residency program. However, the interaction between subcommittees may vary depending on the local context. For example, an EDI subcommittee may provide some oversight or recommendations to other subcommittees, while still being accountable to the RPC.

A subcommittee can be time and human resource intensive. Particularly in smaller programs, there may not be enough individual faculty members to fill a subcommittee. Before establishing a new standing subcommittee, you first should consider whether a less intensive ad hoc working group could be created instead. For recurring tasks, such as those occurring regularly during the academic year cycle, a standing committee is sensible. For time-limited initiatives, you could consider a working group or task force.

Faculty members may be more willing to join a task force struck for a specific purpose. The nature of a task force implies that it dissolves once its purpose has been fulfilled. Working groups or task forces can be used to introduce new curricular requirements, to address areas for improvement identified in internal reviews or Royal College accreditation reviews or to lead a specific quality improvement initiative. Diverting this work away from the RPC will save precious time in your RPC meetings, while RPC oversight is ensured by having the subcommittee or task force report to the RPC

Conclusion

A thoughtfully designed, diverse RPC that meets the standards outlined by the Royal College will set you up for success in your role as program director. This committee will be the backbone of decision-making for your program, the place where everything comes together to ensure you have a high-functioning program that listens and responds to feedback and ensures continuous quality improvement at all levels.

Further reading

• Axtell P. The most productive meetings have fewer than 8 people. Harv Bus Rev. 22 Jun. 2018. Available from: https://hbr.org/2018/06/the-most-productive-meetings-have-fewer-than-8-peopleThis outlines the pitfalls of having a meeting that is too large and outlines considerations in deciding whom to invite to meetings.
• Rady Faculty of Health Sciences. Example RPC terms of reference. Winnipeg: University of Manitoba; 2019. Available from: https://umanitoba.ca/faculties/health_sciences/medicine/education/pgme/media/EXAMPLE_RPC_TERMS_OF_REFERENCE2019.pdf  This sample RPC terms of reference document from the University of Manitoba PGME office provides a detailed outline of the roles and responsibilities of an RPC.
• Knowledge at Wharton Staff. Is your team too big? Too small? What’s the right number? Knowledge at Wharton 2006 Jun. 14. Available from: https://knowledge.wharton.upenn.edu/article/is-your-team-too-big-too-small-whats-the-right-number-2/This article outlines principles behind identifying an appropriate size for a productive team.
• Grigsby RK. Committee, task force, team: What’s the difference? Why does it matter? Acad Physician Sci. 2008 Jan.;4–5.Available from: https://www.aamc.org/media/21586/downloadThis article provides a brief description of the difference between committees, task forces and teams, including benefits of each approach and examples.

References

1. Royal College of Physicians and Surgeons of Canada. General standards of accreditation for residency programs. Ottawa: Royal College of Physicians and Surgeons of Canada; 2020.
2. Rule of Seven. Sigl Creative https://siglcreative.com/2019/06/07/rule-of-7/
3. Rule of Seven. KnowledgeHut.com https://www.knowledgehut.com/tutorials/project-management/the-rule-of-seven
4. Robert HM III, Honemann DH, Balch TJ, Seabold DE, Gerber S. Robert’s rules of order newly revised in brief. 3rd ed. New York (NY): PublicAffairs; 2020.