A framework for role allocation in education, research and leadership services in Canadian academic divisions of general surgery: a modified Delphi consensus
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* Morgann Reid
* Alex Lee
* Ken Leslie
* Liane S. Feldman
* S. Morad Hameed
* Roy Kirkpatrick
* Peter J. Lovrics
* P. Hugh MacDonald
* David Pace
* John M. Shaw
* Carol J. Swallow
* Giuseppe Pagliarello
* David L. Bigam
* Geoff Porter
* Alex Mathieson
* Nathalie McFadden
* Réal Lapointe
* Tony MacLean
* Craig Kuziemsky
* Fady Balaa

## Abstract

**Background:** Moving toward a funding standard similar to that for clinical services for roles essential to the functioning of education, research and leadership services within divisions of general surgery is necessary to strengthen divisional resilience. We aimed to identify roles and underlying tasks in these services central to sustainable functioning of Canadian academic divisions of general surgery.

**Methods:** Between June 2018 and October 2020, we used a 4-step modified Delphi method (online survey, face-to-face nominal group technique [*n* = 12], semistructured telephone interview [*n* = 8] and nominal group technique [*n* = 12]) to achieve national consensus from an expert panel of all 17 heads of academic divisions of general surgery in Canada on the roles and accompanying tasks essential to education, research and leadership services within an academic division of general surgery. We used 70% agreement to determine consensus.

**Results:** The expert panel agreed that a framework for role allocation in education, research and leadership services was relevant and necessary. Consensus was reached for 7 roles within the educational service, 3 roles within the research service and 5 roles within the leadership service.

**Conclusion:** Our framework represents a national consensus that defines role standards for education, research and leadership services in Canadian academic divisions of general surgery. The framework can help divisions build resiliency, and enable sustained and deliberate advances in these services.

Academic divisions of general surgery in Canada are defined by 3 mandates that are core to their mission statements: 1) delivering excellent clinical care, 2) maintaining an accredited training program that graduates competent surgeons and 3) creating a research infrastructure that fosters innovation.1 These services are intrinsically connected and interdependent.2–4 They are enabled by leadership that recognized not only the complexities of each domain, but also that an alignment must occur for the entire division to function (Figure 1). Many divisions of general surgery have mission statements documenting commitments to these domains. However, the existence of a mission statement without tangible support and resources for the key elements can risk authenticity and loss in engagement of members.5 Mission statements should guide the commitment to invest; resource efforts can convert an intended set of values into reality.

![Fig. 1](http://canjsurg.ca/https://www.canjsurg.ca/content/cjs/65/1/E73/F1.medium.gif)

[Fig. 1](http://canjsurg.ca/content/65/1/E73/F1)

Fig. 1 
Academic medical division system where clinical care is a combination of education and research enabled through leadership.

Academic physician remuneration in Canada is still mostly based on a clinical fee-for-service payment model. Whereas provincial standards provide funding and define performance metrics in clinical service, no such detailed guidance is defined for surgical education, research or leadership.6 The responsibility of allocating both human and financial resources for these services generally falls to the local surgical leadership. This can lead to variability in delivery of essential nonclinical services.6 As such, the divisional system that encompasses clinical and nonclinical services is unbalanced and may rely on surgeons’ internal motivations to fulfill responsibilities for many nonclinical services.4,7

Leadership and governance is 1 of the 6 building blocks of a health care system as defined by the World Health Organization, which calls for attention to system design and accountability.8 From a systems management perspective, given the current way in which divisions are modelled and resourced (i.e., predominantly clinical fee-for-service), it is challenging to build a resilient, robust, stable division that enables deliberate advances in education, research or leadership without a framework that rewards these behaviours. A way to strengthen divisional resiliency is to move toward a common funding standard for nonclinical services. However, there is a lack of published information to help guide academic surgical leaders on how best to design a division in a way that formally support essential nonclinical services. The objective of this work was to identify and describe, through national consensus, the roles that are central to support the sustainable functioning of education, research and leadership services within Canadian academic general surgery divisions.

## Methods

We used a 4-step modified Delphi method to gain national consensus on which roles and accompanying tasks are essential for the functioning of education, research and leadership services within Canadian academic general surgery divisions.9,10 This method is in accordance with the *Canadian Journal of Surgery* consensus process.11

An expert panel including all 17 academic general surgery division heads in Canada was recruited through the Canadian Association of General Surgeons Division Chiefs Committee. The first round began in June 2018, when the expert panel members were asked to complete an online survey to gather information on demographic information and identify how nonclinical services (research, education and leadership) were defined and how roles were allocated across various Canadian academic or tertiary hospitals. The insight gained from the responses guided development of the subsequent phases.

In the second round, in September 2018, a panel of 12 of the 17 division heads met face to face in the style of a nominal group technique to discuss the results from the first round. At this time, it was thought that consensus would be achieved on suggested roles and tasks. However, it became apparent that there was substantial disagreement about the definition of nonclinical services, the terminology used to describe services and roles, and how services and roles could be measured. We thus instead sought and obtained validation that the topic area and study were relevant and required further investigation.

In the third round, in April 2019, semistructured telephone interviews were conducted by the first author with 8 division heads from the expert panel to reconcile discrepancies between the suggested roles and tasks, and gain a deeper understanding of the context that was driving these variations. An interview guide was developed based on roles that were discussed from the first and second rounds. Participants were asked whether such roles existed in their organization, to give a description of tasks, and whether there were other roles that should be included as essential. All interviews were recorded and transcribed verbatim by a transcription service. We used a conventional undirected content-analysis methodology adapted from Hsieh and Shannon12 for the qualitative analysis. As there is limited theory and literature on the management of academic divisions of general surgery, we coded for emerging themes using NVivo 12 software (QSR International) and ceased coding after reaching theoretical saturation. The codes and their descriptions were evaluated by 2 authors (M.R. and C.K.) between May and July 2019 to ensure that there was a coherent pattern and agreement in order to increase the confirmability of the findings.

The fourth round was in the style of a nominal group technique. A panel of 12 of the 17 division heads met face to face in September 2019 to discuss the results from the third round and obtain consensus for the developed framework.13 Panel members voted on their agreement to include each role and accompanying tasks as required for the functioning of essential nonclinical services. We used 70% agreement to determine consensus on the acceptance or rejection of a role and accompanying tasks.14 For education services, voting occurred by means of a show of hands, and anonymity was not retained.10 Panel members were encouraged to discuss the roles until agreement was reached to retain, modify or eliminate the role and accompanying tasks from the final framework.10 The panel was asked to provide their vote via email for the remaining research and leadership services by November 2019. We summarized each agreed-upon role and provided a description of how the roles and tasks are organized within each service. An initial draft and then a final iteration of the research findings were circulated among the expert panel members for confirmation.

This study was approved by the Ottawa Health Science Network Research Ethics Board (protocol ID 20180925–01H and 20180926–01H).

## Results

The principal investigator leading the study and administering the online survey (F.B.) did not complete the survey. Of the remaining 16 division heads, 10 (62%) completed the survey. The division heads reported an average of 27 surgeons, 28 residents and 4 fellows. On average, 3 hospitals were affiliated with each division.

The survey showed that most surgeons have additional responsibilities beyond clinical care. These nonclinical responsibilities include education, research and leadership. These responsibilities were defined as follows for the remainder of the study:

*   Education is the delivery and uptake of surgical competencies;

*   Research is knowledge generation and discovery;

*   Leadership is the governance and enabling of people and processes.

The average proportion of divisional funds allocated collectively to education, research and leadership activities was 16.3%. The division heads stated that increasing this amount was either impossible (5 respondents) or would take substantial effort (5 respondents) with their current funding approach.

The expert panel agreed that a framework for role allocation in education, research and leadership services was relevant and necessary.

### Roles and key tasks

The roles and accompanying tasks agreed on through the consensus process were classified according to the 3 nonclinical responsibilities. A role was defined by a set of responsibilities, and tasks were the actions required to fulfill those responsibilities. Although one organization may select a certain position or title to refer to a role, and another organization may choose a different position or title to refer to the same role, the use of common terminology is central to the identification and classification of roles. The tasks associated with each role were classified as micro-level (requiring individual interaction), meso-level (requiring group interactions) or macro-level (requiring institutional interactions). There was recognition that certain roles do not exist in isolation and that there is a need to balance them, depending on organization constraints. For example, smaller divisions or divisions that operate with multiple hospital sites may be unable to delineate specific roles simply because they do not have enough staff.

#### Leadership

The various leadership roles and tasks encompassed a broad range of responsibilities (Table 1). The tasks of the division head reached beyond representing the division to include individual coaching, mentorship and career development. Consensus was achieved around defining other key leadership roles spanning finance, supervision of clinical programs and quality improvement. Responsibilities of the divisional director of finance included leading the acquisition and distribution of funding within the division. The section head role included tasks related to coordination of clinical programs, interfacing with hospital and cross-organizational administration, directing specialty-specific rounds, and incorporating provincial standards to patient care. Quality assurance of division-wide activities was assigned to the quality assurance/improvement lead, and the site chief was responsible for site-specific issues including scheduling and resource allocation.

View this table:
[Table 1](http://canjsurg.ca/content/65/1/E73/T1)

Table 1 
Roles and key tasks for leadership services in an academic division of general surgery

#### Education

Roles in education spanned the entire continuum of support for learners at the undergraduate level to the fellowship training level (Table 2). With regard to postgraduate training, roles to support the program director may include an assistant program director in larger programs and a Competence by Design lead. The surgeons fulfilling these roles may maintain communication with trainees, provide quality assurance and lead critical elements of the program such as chairing a competence committee. Supervision of day-to-day delivery of training was allotted to the section coordinator, who is responsible for defining learning objectives and providing summative evaluations.

View this table:
[Table 2](http://canjsurg.ca/content/65/1/E73/T2)

Table 2 
Roles and key tasks for education services in an academic division of general surgery

#### Research

Last, the expert panel identified surgeon researcher roles (Table 3). Tasks for surgeon-scientists included leading an established research program, whereas surgeon-investigators are responsible for leading or participating in research projects. Within any given academic division, there will be fewer surgeon-scientists than surgeon-investigators, but the specific number will vary depending on the size and nature of the research. The task of advancing divisional research efforts was assigned to the divisional director of research, who provides individual mentorship, builds a divisional research strategy and aim, and creates opportunities for productivity and research dissemination.

View this table:
[Table 3](http://canjsurg.ca/content/65/1/E73/T3)

Table 3 
Roles and key tasks for research services in an academic division of general surgery

### Funding arrangements

Findings from the qualitative analysis showed that participants agreed that funding and funding arrangements are a core tenet related to the roles and tasks required for the 3 nonclinical essential services. There was concern that the breadth of selected roles and any accompanying “invisible” tasks may not be adequately factored into compensation. The following quotation from one of the semistructured interviews highlights the way in which an individual surgeon felt valued by their institution for nonclinical tasks and how that was affected by current funding models:

It’s very blurred, and I get money from the university, and I get money from the hospital. And it’s almost a token amount, but it’s necessary for me because otherwise, if you don’t get any money … what’s the value in it to the university? And what’s the value to the hospital? Even if it’s small. University hospital cut me last year, cut all of us because [of a] budget squeeze. And that was fine. I don’t mind getting cut, but if you said it [the funding] was zero, I might have a problem with it, just because it means that the position isn’t valued. (Division head ID1)

Further findings from the qualitative analysis showed that other roles in education, research or leadership may offer no funding, be less formalized or have vague performance metrics, yet people fulfill these tasks for a variety of reasons, including personal interest and professional development. As illustrated in the following quotation, more comprehensive funding arrangements that enable reduced clinical responsibilities in favour of contributions to education, research or leadership enable a shift to greater collective accountability:

> Asking someone to do something in our centre at the expense of reduced clinical activity usually doesn’t hit the wall as quickly as it might for surgeons who are predominantly funded [via a] fee-for-service arrangement. I think we have a little bit more latitude that way to assign tasks that are, obviously, going to take away from clinical productivity. Collectively we have to meet an accountability framework. Collectively we have to deliver on the clinical side. Individuals have a little more flexibility. (Division head ID5)

## Discussion

To our knowledge, this paper presents the first national consensus framework to guide service structure in Canadian academic divisions of general surgery while addressing the paucity of national standards on resourcing essential roles beyond clinical care. Efforts to support essential nonclinical services formally require a shift in mindset whereby the relations between domains are recognized and actions are taken to support division alignment. The modified Delphi process yielded a systems-based framework that can be used to guide development of a comprehensive and equitable division with sustainable capacity in academic services. There was universal receptivity to mapping the framework across the 3 pillars of education, research and leadership, and to defining the underlying tasks that fulfill these roles. Specific responsibilities under each academic role were stratified into micro-, meso- and macro-level tasks that align with system levels in health care, which each have specific goals, resources and processes that are characteristic to how they function.15,16 Key tasks under each role therefore provide a mechanism to ensure that improvements and solutions to academic services are developed with support from the appropriate people and resources, and are targeted at the appropriate level of the division.

As the framework is grounded in systems management, divisions across Canada will be able to foster a common model of service structure that enhances authenticity to their mission statements, increases accountability and governance, and provides a guide for resource allocation and investment in these services. However, in adopting the selected roles and tasks, divisions need to take into consideration their local context to determine whether the roles and tasks are justified and feasible. Notably, some roles may depend on the size of the program or may share representation with the medical department or faculty. Moreover, the responsibilities under these roles are expected to evolve over time with advancements in curricula and research. The position of a Competence by Design lead, for example, must be adaptive to nation-wide transitions from an apprenticeship model to an outcome-based curriculum paradigm based on the evolving standards for resident training.17–19

Achieving concurrent success in all domains of clinical and nonclinical services with the use of this framework will require a shift from striving for individual success to aiming for collective success in the academic division by employing systems-based management. Systems-based management convenes a variety of formal approaches to frame complexities in health care management as interdependent components within the larger system entity.20–22

Although a shift away from focus on the individual surgeon may seem counterintuitive to enhancing provider experience, a governance system that is designed to enable collective identity and responsibility around education, research and leadership can enable a more positive provider experience.23 For example, clinicians could lead aspects of divisional responsibilities pertaining to their skill sets and career goals (e.g., interest in educational services) but hold more supportive roles and accountabilities with respect to other nonclinical services that are not their primary focus, all of which would contribute to collective divisional success.23 This could be achieved by designing a flexible division with dedicated funding for nonclinical roles and responsibilities. Such a strategy must ultimately embrace a more balanced funding model of fee-for-divisional service where divisional services include education, research and leadership, allowing divisions to better align themselves with their objectives in both clinical and nonclinical services. By linking these services, decisionmakers can maintain divisional resiliency when pressures threaten to disrupt an individual service (such as when the COVID-19 pandemic threatened funding of certain clinical services and altered funding of research areas).24 The local leadership will be in the best position to determine a suitable mechanism for implementing such a model. However, one possible mechanism is to have internal taxation or tithing system whereby a proportion of total divisional earnings are redistributed to fund the essential nonclinical services. Furthermore, a division could implement “day rates” whereby a surgeon would be compensated at a standard rate per hour or per day for completing tasks specific to an essential role in education, research or leadership.

Although the 17 Canadian academic divisions of general surgery exhibit considerable heterogeneity with respect to size, geographic location and funding models, consensus achieved in this study shows that these divisions share a similar mission with regard to the 3 pillars of nonclinical academic services.1 By identifying the roles needed to maintain and advance essential nonclinical services, the framework that we present can be used to deliver on a division’s mission statement by recognizing the value of these services while providing a blueprint through which divisional leadership can guide strategies and investment when determining responsibilities and compensation. Nationally, this framework represents a common syntax around structuring academic services in general surgery, and fosters a platform for interdivisional learning and discussion of strategies that enhance the value of these roles. In turn, leaders can streamline workforce planning by better predicting which skills are needed for specific tasks and which skills may contribute to better retention through professional development opportunities and recruitment rates.

For the individual provider, a divisional structure that allocates resources and funding based on the presented framework can ultimately be used to improve surgeon morale and sense of belonging to the division. It is well understood that financial incentives do not fully explain why surgeons strive to provide excellent clinical care, research innovation and role model as teachers.7,25,26 Non-financial motivators and other prosocial behaviours (e.g., desire for personal growth, promotion and tenure, being part of a team) surely contribute. However, relying on a clinician’s intrinsic motivation instead of designing a system to formally support the individual is a precarious way to create individual accountability and does not lend well to overall divisional accountability and success. Simultaneous mastery across the entire spectrum of clinical care, education, research and leadership is difficult to achieve when traditional service models (i.e., clinical fee-for-service) do not protect time for these roles, the result of which has been heightened awareness in the literature on increasing clinical well-being and reducing burnout rates.27–30 The presented framework offers a guide on how divisions can invest resources in essential services beyond clinical care, thereby showing the value of a surgeon’s contribution and, at the time same time, increasing divisional resiliency.

This study spanned several years and iterative steps, including semistructured interviews, to comprehensively achieve consensus among the expert panel. We defined roles and tasks while keeping in mind the variability that may exist depending on the local context of the division and the advances in surgical education and research. As such, this framework represents a national consensus that defines current standards and can also guide future advances in nonclinical service structure in general surgery. A natural extension of this framework includes assessing the time required by each role, which could provide a starting point for divisional investment.

### Limitations

Although no data were collected from stakeholders other than division heads in academic divisions of general surgery, division heads are responsible for representing their respective divisions while understanding and overseeing the entire functioning of their clinical and nonclinical programs. This makes them appropriate participants for this study. However, more granularity would have been gained by engaging other roles in the expert panel, such as program director, director of finance or surgeon-scientist.

## Conclusion

We used a modified Delphi process to generate a national consensus framework to guide role allocation in education, research and leadership services in Canadian academic divisions of general surgery. Adopting and advancing a divisional system that enables collective identity and responsibility around these essential nonclinical services will require a mechanism for accountability and performance measurement. The set of tasks outlined for each role in this framework can help apply uniform rules and standards that can also be measured to assess performance as a mechanism for accountability. From a system management perspective, the resultant division will be more resilient to external pressures and better positioned to cultivate the skill sets of the workforce to authentically deliver on its mission statement pertaining to clinical care, education, research and leadership.

## Acknowledgements

The authors thank Dawn Wilson for her help in coordinating the face-to-face meetings, and Dr. Caolan Walsh for his work in design of the survey.

## Footnotes

*   **Competing interests:** Tony MacLean reports an honorarium from Ethicon. No other competing interests were declared.

*   **Contributors:** M. Reid, L. Feldman, A. Mathieson, C. Kuziemsky and F. Balaa designed the study. M. Reid, K. Leslie, R. Kirkpatrick, H. MacDonald, D. Pace, J. Shaw, C. Swallow, G. Pagliarello, N. McFadden, T. MacLean, C. Kuziemsky, D. Bigam and G. Porter acquired the data, which M. Reid, A. Lee, L. Feldman, M. Hameed, P. Lovrics, H. MacDonald, J. Shaw, R. Lapointe, T. MacLean and F. Balaa analyzed. M. Reid, A. Lee and F. Balaa wrote the manuscript, which all authors critically revised. All authors gave final approval of the article to be published.

*   **Funding:** This work was supported through the University of Ottawa Interdisciplinary Research Group Funding Opportunity.

*   Accepted February 9, 2021.

This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY-NC-ND 4.0) licence, which permits use, distribution and reproduction in any medium, provided that the original publication is properly cited, the use is noncommercial (i.e., research or educational use), and no modifications or adaptations are made. See: [https://creativecommons.org/licenses/by-nc-nd/4.0/](https://creativecommons.org/licenses/by-nc-nd/4.0/)

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