JCC Showcase – Session Abstracts

A1: Coordination of Care

The BC Inherited Arrhythmia Program: Evidence-Based, Accessible, Family-Centered Approach to Quality Care 

The BC Inherited Arrhythmia Program (BCIAP) is a provincial multidisciplinary initiative that launched in April 2013. Over the last 2 years, innovative efforts have been made to deliver quality care by developing expertise around inherited arrhythmias, improving access, increasing capacity and streamlining care.

Methods: Bi-monthly rounds and BCIAP team meetings were planned to enhance education and develop protocols. Distributed care is facilitated by using local clinical systems partnered with videoconference encounters and outreach clinics. A family-centered care approach is taken through combined adult/pediatric clinics and family visits. Communication tools were created to enable evaluation of family members.

Seven multidisciplinary rounds have been held since the program’s start with an additional 5 BCIAP team meetings in the second year to develop 4 management protocols (Sudden Infant Death Syndrome, Genetic Testing in Unexplained Cardiac Arrest, Genetic Testing in Long QT syndrome, Pregnancy and Neonatal Management in Long QT syndrome). Telehealth encounters were initiated at St. Paul’s Hospital in the second year and accounted for 11% of visits. Four additional outreach clinics (total of 12) were held in Northern BC in the second year for an increase of 42% of patient encounters, with 2 clinics attended by a pediatric electrophysiologist (EP). Over 200 families are followed; 40% of visits at one site were attended by 2 or more relatives and 40% of families are followed jointly by adult and pediatric EPs. A total of 118 targeted familial mutation tests have been ordered; 55% more in the second year than in the first.

Conclusion: Program initiatives have led to growth, increased access and awareness. Focusing on under served areas and implementing evidence-based protocols to ensure consistent approaches across the province aim to improve the quality of care. Physician funding for program development enables these processes.

Successful Implementation of a Prostate Cancer Survivorship Program

Treatment for localized prostate cancer (PC) can adversely impact the quality of life for the patient and his partner. Addition of androgen deprivation therapy (ADT) to treat biochemical relapse or metastatic disease can result in further symptoms. We hypothesized that a clinical, educational, research-based approach to care focusing on disease specific needs would be beneficial.

Funding from the Specialist Services Committee (SSC) was used to establish a survivorship program in the urology clinic at the Vancouver Prostate Centre overseen by a multi-disciplinary management team. The Prostate Cancer Supportive Care (PCSC) Program was initiated in January 2013 and was organized around 5 thematic modules allowing patients to select those which appealed to them 1) information about PC and primary treatment options, 2) sexual health and intimacy, 3) lifestyle changes, 4) managing the side effects of ADT, 5) incontinence and pelvic floor physiotherapy. Group educational sessions are held 1-2 times monthly for each module along with clinical services.

PCSC grew steadily since inception and serves an increasing community of prostate cancer patients, partners, and family members in the greater Vancouver area with referrals by urologists, nurses, pharmacists, and radiation oncologists. Of 802 patients who enrolled (167 in 2013, 369 in 2014, and 266 in 2015 to date), 626 (78%) have chosen to participate in at least one module of PCSC. Feedback from couples, participating clinicians, and allied health personnel has been overwhelmingly positive.

In 2015, PCSC received further funding from the SSC to create the ‘PCSC Network’ at two additional sites in BC. After reviewing responses to an expression of interest, two sites will be selected to adopt the program. We will develop programs to train healthcare professionals in sexual health and male pelvic floor physiotherapy at these sites. Outcomes research will be done at all sites to assess effectiveness.

Developing a Multidisciplinary Fragile X and Related Conditions Clinic in Victoria, BC

Background: Fragile-X syndrome (FXS), being the most common form of inherited intellectual disability, remains a rare disorder. Families living with FXS and related conditions in British Columbia (BC) are believed to lack healthcare involvement with clinical expertise. Access to appropriate services, diagnostic assessments and specialized management recommendations is essential to optimal care for these patients.

Objectives: Develop a clinical-model of multidisciplinary, family-centred care for FXS families; improved patient care through coordinated, specialist assessments; increased clinical expertise for healthcare professionals, and increased public and professional awareness of clinical services for FXS and related conditions.

Design/Method: The Fragile X and Related Conditions (FXRC) clinic was established January 2015 with Doctors of BC, Specialist Services Committee (DOBC/SSC) funding. A clinic coordinator was hired to implement objectives. Public and professional awareness of services is tracked through social media and referrals to the clinic. An FXRC conference is planned with leading FXS specialists providing relevant information to parents and professionals.

Results: FXRC achievements include establishing a resource-based website, developing an active social media presence to share collaborative information with Fragile X families, professionals and community groups, multiple presentations to differing medical disciplines including pediatrics, psychiatry and perinatal services. A retrospective chart review from medical genetics identified 65 local individuals with a personal or family history of FXS.

Conclusions: FXRC implementation has been challenging despite DOBC/SSC support. Although early systemic barriers hindered clinic development, current feedback has been positive from a wide range of health and administrative professionals. Coordination of specialist care, together with identifying the spectrum nature of FMR1 disorders, has been key to our success.

A2: Seniors Care

Leveraging Resources to Create New Community Culture, a COPD Example

Resource leveraging is a common term in business circles. BusinessDictionary.com defines leveraging as: “the ability to influence a system, or an environment, in a way that multiplies the outcome of one’s efforts without a corresponding increase in the consumption of resources.” Healthcare seems a natural fit for a practice that increases outcomes without increasing resources.

An interdisciplinary team in the South Okanagan Similkameen demonstrated the applicability of leveraging resources around Chronic Obstructive Pulmonary Disease (COPD) to create culture change.

COPD was consistently the number one reason for readmission to hospital in Penticton. With a prevalence of over 7000 COPD patients and growing, complications due to COPD are a significant burden on the healthcare system.

Three years after an interdisciplinary team started work on the issue, COPD readmissions had fallen 32% – making it number three on the list. Why? The team leveraged the resources of multiple organizations to implement a COPD pathway that operationalized evidence-based best practice. The result was a culture change around the disease.

The culture change happened in 7 communities, among over 150 doctors, and impacted over 7000 patients. The COPD pathway has now been in place for two years and still guides COPD care in our communities despite staffing changes.

The organizations involved with implementation each brought a different expertise and different resources to the project. The Division of Family Practice physicians, local specialists, the Physician Information Technology Office, Interior Health Authority’s respiratory therapy team and Practice Support Program, and the COPD Shared Care project team all targeted their resources strategically to change culture.

In this interactive workshop, members of the interdisciplinary team will take participants through the steps required to leverage resources and operationalize culture change in a community.

The CARES Quality Improvement Project – Preventing Frailty in Seniors

CARES Abstract
A rapidly aging population pre-disposed toward frailty is placing increasing pressure on the healthcare system. Frailty is a common and potentially life threatening geriatric syndrome associated with adverse health outcomes and increased reliance on health care resources. Emerging research demonstrates there are natural protective factors to frailty and it is possible to delay or slow the progression of frailty. Without intervention seniors are at risk for becoming frail unnecessarily.

The EXTRA project, Community Actions and Resources Empowering Seniors (CARES) partners primary care providers, their pre frail patients and community based trained coaches to enact wellness plans that integrate health protective factors into the senior’s life. It enhances skills, resources and education for primary care providers on frailty prevention while engaging the senior in the development and management of their own wellness plan. It ensures compliance with the wellness plans by connecting seniors with community based coaches. Trained coaches work with seniors over a period of six months to support the continued and effective integration of the health protective factors.

The CARES project is a joint initiative between two Canadian healthcare jurisdictions, Fraser Health Authority in BC and Nova Scotia Health Authority, Halifax. The CARES project has successfully integrated primary care providers, health authority and community resources to enact health protective wellness plans to delay and prevent frailty showing improved frailty scores over a six month period in pre frail seniors. Early findings are positive in multiple measurement domains. It is anticipated improved frailty scores will enable seniors to age well and reduce their utilization on health care resources.

From Patient Data to Meaningful Information: The Clinical Relevance of My EMR Data 

The Kootenay Boundary Division of Family Practice, a community-based group of family physicians working together to achieve common health care goals, embarked on a Quality Improvement through EMR Initiative. This multi-year plan involves a number of multi-stakeholder projects. Its goal is that all physicians (and staff) within the Kootenay Boundary are provided opportunities to see the value in entering quality data into the Electronic Medical Record (EMR), receive the necessary training and support, and proactively generate reports for various conditions under a quality improvement model within their practice. The initiative explores the notion that a culture of quality improvement is founded on three pillars: quality data, motivated physicians and advanced EMR technology. This project focuses on quality improvement resulting from small group learning sessions arising from the development and implementation of an EMR clinical reports of importance in the region.

The project objectives include:

  • Implement a clinical/polypharmacy reports in the EMR
  • Explore a coaching model to educate and motivate physicians to enter quality EMR data
  • Use the reports to reflect individually and in small group on data quality learnings and physician’s best practice patient care. Methodology/Approach

Physicians in Kootenay Boundary were provided an opportunity to participate in the project. The project leveraged new advanced EMR report functionality. The participants were provided a ‘how-to’ generate your first EMR query guide, followed by one-on-one coaching sessions (if required) in order to explore the report’s meaning and data validity. Specifically, physicians were able to drill down to patient-level EMR data from the report in order to explore issues of data quality. Small group sessions were used to gain insight into the project’s clinical/polypharmacy questions related to best practices and regional population-level comparisons. Rapid Plan-Do-Study-Act cycles were used to evaluate the report’s usage, changes to the quality of data entered in the EMR and changes in physicians’ best practice patient care. Findings/Results; The findings will be presented. Next Steps/ Conclusions; It is expected that this project will provide the foundation for additional quality improvement projects within the region and throughout the province of BC.


A3: Advances in Surgical Improvement

Improving Outcomes in Colorectal Surgery

Standardized care protocols to improve care for colorectal surgery patients were sequentially introduced at a community hospital. These initiatives included a Surgical Site Infection Bundle (SSI) and an Enhanced Recovery After Surgery pathway (ERAS). The purpose of this study is to determine if there was additive benefit with the introduction of these initiatives.

Study Design
Patients at a single institution who underwent elective colorectal surgery between the dates April 1, 2011 – May 31, 2015 were identified using NSQIP data. The cohort of patients was stratified into 3 groups by implementation dates for the initiatives. This included a pre-initiative group (April 1, 2011 – June 16, 2013); a post-SSI/pre-ERAS group (June 17, 2013 – May 20, 2014); and a post-initiative group (May 21, 2014 – May 31, 2015). Characteristics of the groups and their 30-day outcomes were assessed. Inverse proportional weighting (IPW) was used to control for possible differences between the groups.

There were 287 patients included: 95, 95, and 98 in the pre-initiative, post SSI/pre ERAS, and post-initiative groups respectively. The groups were balanced with respect to procedural and patient characteristics using IPW. The post SSI/pre ERAS group had a lower SSI rate but no difference in length of stay (LOS) compared to the pre-intervention group. The post intervention group had a further reduction in SSI and overall morbidity and a decrease in LOS compared to the other groups.

The combination of SSI and ERAS initiatives yielded additive benefit for patients undergoing colorectal surgery with decrease in morbidity and length of stay.

Jumpstarting QI in the Richmond Hospital OR

Context: In Spring 2014, Richmond Hospital joined the VCH initiative to improve teamwork and communication utilizing The Productive Operating Theater (TPOT) modules. We have initiated engagement within the perioperative team to improve quality, patient safety and efficiencies.

Problem/Issue: The visioning workshop, attended by all members of the perioperative team, identified that communication, teamwork, and starting and ending on schedule were the areas that required the most attention.

Intervention: Our core team is comprised of a physician lead, hospital management, quality specialists, and frontline perioperative staff. This infrastructure did not exist previously. The need for punctuality and to improve communication between team members lead to implementation of a “Start Your Day Right Huddle”. The huddle, beginning fifteen minutes before a room’s first case, encourages the surgeon, anesthetist, and nurses to discuss an overview of the day. To improve turnover time, nursing prepares the room for housekeeping staff and takes breaks in a way that optimizes staffing for procedure set-ups. Our surgeon champion speaks at monthly department of surgery meetings to provide updates. This has motivated our surgeons to participate in the huddle and start on time.

Measurement: Since implementation of the Huddle, first case start times have improved by ten percent. Furthermore, the crowning achievement to date is the Plastic Surgery team achieving three breast reductions in one day while finishing ahead of schedule. Previously, only two breast reduction surgeries were able to be scheduled in one day.

Challenges & Lessons Learned: The implementation of TPOT thus far has added structure to identifying problems and identifying possible solutions. It has become clear that management support is crucial to bypassing roadblocks. Additionally, consistency is needed for perioperative leaders to have regularly scheduled days dedicated to TPOT improvements.

Audit of Multimodal Pain Management within an ERAS Program

Introduction: Optimization of pain management using multimodal therapy is a key component of an Enhanced Recovery Surgery Program (ERAS). Multimodal analgesia is defined as the use of >one modality of pain control to achieve effective analgesia while reducing opioid-related side effects. We audited our use of specific non-opioid modalities with the implementation of our ERAS program.

Methods: The charts of 174 elective colorectal procedures performed between November 2013 and August 2014 were reviewed assessing the type of analgesia methods, analgesics requirements, postoperative complications & length of stay(LOS). We compared post-implementation rates with our pre-existing ACS NSQIP database prior to implementation (July 2011-June 2013). Chi-square, Fisher’s exact, and student t-tests were used as appropriate.

Results: Multimodal analgesia was administered in 76.2% of cases (81.4% of open versus 64.5% of MIS cases.) 18.4% of cases received three non-opioid modalities, and 5.2% had >4 modalities and this varied by type of procedure. The use of a lidocaine infusion was associated with a significant decrease in rescue analgesia in the recovery room. The average requirements of fentanyl and hydromorphone in the lidocaine group were significantly lower; fentanyl mean (SD) 34.2 (59) ug versus 82.7 (78) ug, {p<0.05}, and hydomorphone mean (SD) 0.79 (1.2) vs 1.46 (1.3) {p<0.05}. Lidocaine infusions were also associated with a reduced incidence of excessive pain in PACU, 4.25% vs 18.4% {p<0.05}. Post implementation of our ERAS program, the morbidity incidence decreased by almost 50%, from 27.3% to 14% {p<0.05}. Median LOS (IQR) was reduced from 7 (5-11) to 5 (4-8) days.

Conclusion: Despite the continuously expanding array of multi-modal analgesia methods, postoperative pain may be under-managed, as almost 1/3 of our MIS cases did not receive multimodal analgesia. The implementation our local ERAS program has resulted in a significant reduction in complications and hospital length of stay.

A4: Coming Together to Create Change: Child Youth Mental Health & Substance Use

The Child & Youth Mental Health and Substance Use Collaborative

The Child and Youth Mental Health and Substance Use (CYMHSU) Collaborative is the largest Quality Improvement initiative in British Columbia, funded in partnership by the Shared Care Committee, General Practice Services Committee and the Specialist Service Committee, and sponsored by five regional health authorities and government Ministries of Health; Children and Family Development; and Education. This initiative has successfully engaged over 150 physicians for an improved system of care for children and youth.

Pediatricians, psychiatrists and family physicians are working to implement meaningful change at the community level in collaboration with community service providers, school representatives, police, administrators, aboriginal representatives and youth and parents with lived experience.

Two years into a four-year Collaborative, we have learned valuable lessons in terms of how to best support system change with diverse stakeholders. Including: How to recruit, orient and support youth and parents; how to balance the strategic needs of different sponsoring organizations; how to support community level change within a broader system of care; how to uncover and remove systemic barriers to best care, and how to plan for sustainability on a broad scale.

To date the CYMHSU Collaborative has achieved:
• Over 150 physicians engaged in driving local and provincial system change
• connections between providers to increase collaboration and peer support across the province and coordinate care for children, youth and their families
• Local Action Teams in over 50 communities
• 10 working groups tackling system level barriers in areas such as Emergency Department protocols, youth to adult transitions, information sharing and physician compensation.
• Measurement strategies to monitor child and youth mental health and substance use outcomes at a provincial level from disparate data bases and the use of narratives
• 112 youth and parents engaged in the initiative as of June 2015
• Early exploration of options for youth and parent feedback informed care

B1: Local Solutions

Improving Palliative Care in Powell River

In its 2015 Primary and Community health policy paper, the Ministry of Health identifies the importance of palliative care, especially for an aging population. It highlights issues of fragmentation, and care planning and coordination between healthcare professionals. In Powell River, an isolated community of 20,000 people with many seniors (23.4% compared to 16.3% in BC), similar issues exist. A 2014 physician survey identified lack of clarity in roles and responsibilities between healthcare professionals, and lack of nursing staff education, bereavement counseling and community support for patients and their families. Powell River Division of Family Practice, together with Vancouver Coastal Health and Hospice society received funding from Shared Care to address these issues.

• A working group of a family doctor, social worker, and nurses, review workflow and communication processes, and proposes improvements.
• The palliative approach is being standardized across different health professionals.
• End of life training for family doctors and allied healthcare professionals is developed and delivered in collaboration with General Practise Services Committee’s Practice Support Program
• A marketing campaign is developed, including a large public forum.

Potential/Actual impact:
The project team expects by March 31, 2016 to improve:
• communication between healthcare providers;
• coordination of care;
• patients’ and caregivers’ experience;
• perception and understanding of palliative care.
Ultimately this will lead to an increase of home deaths, and a reduction of ER visits and admissions of palliative patients through ER
Healthcare providers are already reporting increased awareness and communication improvements.

Evaluation strategy:
The project uses a developmental evaluation approach, developing measurements parallel to the evolving project. Examples of indicators:
• Increase in usage of communication tools, i.e. the Palliative Performance Scale (PPS)
• Perception of healthcare providers on communication improvements
• Increase of referrals to Home and Community Care from family doctors of patients at PPS 50%

Preliminary results are expected early 2016.

Co-creating a New Physician Culture

At Cowichan District Hospital, through many discussions with doctors, we noticed a general decrease in physician engagement. But we also noticed increasing effectiveness of the Division of Family Practice.

From the Nuka System of Care we assumed that engaging physicians’ dormant cultural values would release an inherent interest in quality improvement. With this assumption we engaged two surgeons representative of the Department of Surgery and a Family Doctor representative of the DFP, the Executive Director of the DFP and an evaluator to answer this question: “How can we best deliver surgical care in Cowichan communities?” We focused on culture by interpreting “Plan Do Study Act” (PDSA) cycles to mean we would decide what to talk about, talk about it, reflect on that talk, decide what to do with that, and then repeat the cycle. We agreed to listen on purpose and with respect for diversity. We met ten times for 2 to 3 hours.

We quickly established a context of safety by assuring
a) this was a doctors’ project
b) we would intentionally not disrupt our system of surgical care by carelessly insulting anyone.

We accomplished a number of things:
1. Our assumption about culture’s central role is correct.
2. Using “PDSA” cycles to engage is effective and efficient.
3. We discussed improving physician wellbeing, succession planning, conflict resolution, intricacies of referral and consultation, delegation and timing of responsibility.
4. We surveyed the Division of Family Practice and the Department Of Surgery with the question: “What could we offer each other to improve surgical care?” The results are combined in a “charter” intended as a legacy for Cowichan physicians to review.
5. We produced a novel evaluation framework based on the Collective Impact movement.
6. Word of our discussions inspired local physicians to form a new facility based medical society.

Working Together for Rural Patients

The quality of life and health outcomes for rural residents in Princeton BC are improving as a result of increased specialist visits to the community. Thirteen specialists are providing patient consultations, as well as on-site continuing medical education (CME) for GPs. Patients with chronic health concerns are travelling less, and are significantly more likely to access specialist care. The family physicians are reporting less isolation, better ability to provide patient care, and renewed strength in recruitment and retention.

Located in the southern interior, the Princeton Local Health Area (pop. 5400) is served by a small local hospital. No specialists reside locally and retaining family physicians has been a persistent challenge. Tertiary care requires that patients travel 3 hours through mountainous terrain.

In 2013, Penticton specialists and Princeton family physicians catalyzed the Shared Care project to improve access to care and advice. In collaboration with the health authority they developed, implemented and tested outreach clinic formats aiming to locate appropriate specialist care in Princeton. Together they navigated the challenges of engaging specialists, shaping patient referral and booking procedures, meeting diverse clinic equipment and set up requirements, and establishing a sustainable travel funding process.

By the end of 2014, approximately 500 patient appointments were held in 46 outreach clinics covering 11 different specialty areas. Data showed 96% of patients kept their appointments, while 31% had missed appointments in the past due to travel difficulties. In addition, 9 accredited lunchtime CMEs were offered to the rural practitioners specific to their needs.

Participating specialists welcome the variety in their practice and find the outreach rewarding. Built with existing resources, this replicable patient-centered model of care is contributing to the sustainability of rural practice, and enhancing the job satisfaction of all of those involved.

B2: Maternity Care

Building a Maternity Care Network in Urban Family Practice

Urban family physicians’ role in maternity care has reduced due to increasing complexity of obstetrical care, difficulty balancing office/hospital practice, and insufficient caseload to maintain competency. The Vancouver Division of Family Practice (VDoFP) has identified maternity care as a priority area, given that all FPs provide care to pregnant women, whether or not they attend births.

The workshop series for family physicians who do not attend births is a partnership between VDoFP, UBC Continuing Professional Development, and Practice Support Program (PSP). Presentations cover best practices in maternity care; case studies and resources facilitate knowledge application. Table discussions facilitated by family physicians providing full-spectrum maternity care maximize mentorship, network building, and referral opportunities. Individual data on prenatal genetic screening and evidence-based, individualized practice coaching sessions from PSP serve as tools for practice change. PSP practice coaching is a service that provides physicians and their staff with assistance to implement and sustain changes in their practice that result in higher quality and more efficient maternity care. Pre/post surveys and written reflections capture the impact of the workshop.

328 participants attended seven workshops. Participants’ comfort in providing maternity care increased significantly from before (M=4.36/7, SD=1.55) to after workshops (M=5.11/7, SD=1.37); t(387)=5.34, p

Workshops addressed a perceived need within urban practice. This novel approach of collaboration between CPD providers, physician organizations, and the PSP to facilitate knowledge exchange, mentorship, quality improvement, and cultivation of a maternity care network is applicable to other contexts.


B3: Hip Fracture Redesign

Data Driven Decision Making, the Provincial Hip Fracture Redesign Initiative

Hip fractures in elderly British Columbians represent a significant public health burden due to their frequency (approx. 3,500/yr) and the expected growth in numbers. Hip Fractures are the most expensive surgical admission and result in loss of mobility, independence and death for many. Utilization of population-level Quality Improvement initiatives in the UK and Sweden and the Canadian Hip Fracture Toolkit have informed best practices guiding care decisions. Despite these resources many sites in BC inconsistently apply these practices for hip patients or have no specific care plan at all.

Wide variations in care and absence of universally applied standards offer the opportunity for improvement. The goals of the BCHFR Initiative are to 1) Quantify the gaps in care at all 28 sites; 2) Define quality indicators to reflect best practice care and develop a secure data management process; 3) Complete a change management initiative in 8 pilot sites; 4) Quantitatively report on the outcomes.

Design of a project database to combine real-time site data with secondary data from the Ministry of Health holdings to measure and report on a range of quality indicators defined by the project.

The project defined 30 quality indicators to measure and reflect on the patient’s entire journey from fracture back to community. Outcome measures demonstrate improvements in 6 quality domains: access, patient-centeredness, efficiency, effectiveness, safety and appropriateness.

– Data collection fatigue and competing priorities
– Responsiveness and timeliness of data analysis and report out to site demands

The processes and tools can be applied to other sites in BC and to other health conditions.

Catching the Waves – Best Practices, BC Hip Fracture Redesign

Approximately 3,500 British Columbians fracture their hip each year. Contributing factors are often foreseeable and preventable. A survey of hip fracture care at 28 BC hospitals identified improvement needs.

Hip fracture patients have high morbidity and mortality due to advanced age, delays to surgery, lack of care coordination and care-related complications. The goal of the BC Hip Fracture Redesign Initiative is to systematically measure performance and standardize best practices to lower mortality and post-operative complications, reduce readmissions and improve patient flow.

8 pilot sites collaborated to develop evidence-based interdisciplinary strategies to introduce best practices and improve the patient/provider experience through:
– Reducing wait times for patients to access surgery
– Introducing guidelines to support reversal of anti-coagulation medications
– Creating standardized best practice content for physician orders
– Co-producing a patient / family education booklet called “Fresh Start “
– Preparing communication tools to facilitate transitions /hand-offs in care for patients coming in and leaving hospital
– Sharing best practices for health care providers through a modular topic-specific education toolkit
– Identifying opportunities for improving access to rehabilitation services post hospital discharge
– Creating a website, posters, video, storyboards to facilitate sharing of information

A real-time project database captured a number of performance measures to improve the health of the hip fracture population, enhance the patient/provider experience and reduce /control per capita costs.

– Data collection fatigue and competing priorities
– Clear deliverables and engaging site champions to report on progress are key to ongoing sustainment of change.

A measurement-based approach has supported incremental spread of best practices throughout the province.

B4: Child Youth Mental Health & Substance Use

The Road to Hope

“Failing Grace: The Story of Chloe Grace Highley” aired on CBC the week of May 4th, 2015. Chloe Highley was a well-known 18-year-old who died of an accidental heroin overdose in Penticton. CBC describes: “for Chloe’s parents, it was the tragic end to an urgent and heartbreaking battle to get their daughter help for anxiety, depression and drugs.” Sadly, Chloe’s death was not an isolated event.

May 4th also marked the start of Mental Health Awareness Week and it coincided with a regularly-scheduled meeting of the Penticton Local Action Team, part of the Child and Youth Mental Health and Substance Use Collaborative.

This watershed moment became a catalyst for our Local Action Team to gather the community around child and youth mental health and substance use. The team was quickly infused with new members, creating a momentum that carried the Local Action Team through an ambitious summer schedule of working meetings. Clinicians, educators and community members attended meetings even while on vacation because they were invested – personally and professionally.

While this movement is still germinating, there is no doubt that practices are shifting. In response to results of a quality improvement review of local youth journeys, plans are underway to trial an interdisciplinary intensive care management team for high-risk youth. The intent is to tailor services to youth needs and maximize scarce resources. To prevent more tragedies, youth, parents, educators and clinicians are partnering to offer peer and parent support programs. These initiatives will be tested, evaluated and implemented where they are making a difference.

Members of the Local Action Team will tell their story and offer participants in this workshop advice and tools from our experience that other communities may be able to use.

Enhancing Care in Children & Youth Mental Health and Substance Use

Access to child and adolescent psychiatrists in BC is limited. There are approximately 84,000 children and youth in BC who meet full DSM IV TR criteria for a mental health disorder. Of these, access data tell us that approximately 26, 000/year receive services from MCFD Child and Youth Mental Health Teams in communities throughout BC and 3,500/year access tertiary mental health services at BC Children’s Hospital, leaving the vast majority of children and youth with mental health disorders not identified, assessed or treated.

In communities throughout BC, pediatricians and general psychiatrists are called upon to provide consultation for children and youth with psychiatric illnesses. Feedback from these practitioners indicates that they would like to have more in-depth training in child and adolescent psychiatry in order to manage these consultative expectations.

BC Mental Health and Substance Use Services received two-year funding from the Doctors of BC and Ministry of Health’s Shared Care Committee, with a contribution from the Specialist Services Committee, to support the development of enhanced online learning series in child and adolescent psychiatry for pediatricians and general psychiatrists. This project aims to improve access for children, youth and families to medical specialists with expertise in child and adolescent psychiatry. The Specialist Practice Learning Series will serve the whole province, with a special focus on rural and remote areas with limited access to child psychiatry services.

The Learning Series Steering Committees was critical to the success of the project by guiding the project and working through challenges, including the development of a resource format and content that would be acceptable and engaging.

The Learning Series will be pilot tested with pediatricians and general psychiatrists across BC in January 2016 with implementation scheduled for spring 2016. A robust evaluation framework has been developed to help assess the effectiveness of the resource.

Communication is Key: A Case Study of the John Barsby Wellness Centre

The John Barsby Wellness Centre (JBWC) aims to provide holistic health and wellness services to students in Nanaimo’s most vulnerable high school setting. The JBWC integrates primary care with health promotion, specialist services, and youth-focused MHSU services. The Nanaimo Division’s involvement with the JBWC is closely tied to their A GP for Me initiative: attaching students to a primary care home is a common goal amongst all partners.

The initial Working Group consisted of four members and has since grown to over 30 members representing 19 different partner agencies/organizations. When the group elected to become a Local Action Team of the CYMHSU Collaborative in early 2015, membership and opportunities for collaboration once again grew exponentially.

The challenges of working with such a large group have resulted in the consolidation of members to form an Operations Council, made up of primary partners who oversee the operational aspects of the Centre. Group dynamics have been, at times, contentious and in need of devoted conversation. Thorough and deliberate communication has proven essential to working with such a large group and the values and vision of the work have been revisited constantly throughout the process, including an externally facilitated Visioning Session and regular strategic conversations between all partners. Even with this dedication, the Division feels that communication continues to be the largest hurdle to ensuring success at the JBWC.

With its recent opening, the actual impacts of the centre have yet to be felt, though it is estimated that the JBWC will attach 200 youth to a primary medical home. A baseline survey was administered in spring 2014 with a student experience survey to be launched at the onset of services to track the satisfaction and use of services for first-time users as well as a post-use survey to track multiple-visit satisfaction.

C1: E-Enabled Virtual Care

Island Health Telemental Health Expansion Project – Removing Barriers to Care 

The Island Health TeleMental Health Expansion Project began in September 2013 with the goal of bringing mental health services to patients living in remote and rural areas of Vancouver Island by using Telehealth equipment for service delivery. These areas faced a shortage of psychiatrists and wait times were significant. The introduction of the Telehealth model was seen as a way to improve timely access to care, reduce the need to travel, prevent deterioration in the patient’s condition and hospitalization and to support rural and remote primary care practitioners.

Five patient locations (Port Hardy, Campbell River, Ucluelet, Port Alberni and Oceanside) and one provider site (Victoria) were chosen for the project. The model had patients attend their local Mental Health and Substance Use Services office with the support of an attending mental health clinician and connect with a Victoria-based psychiatrist over Telehealth video-conferencing equipment.

After bringing the service to the first two locations, news of TeleMental Health spread and eight additional client locations were added across the north island and the southern Gulf Islands. Provider sites also expanded to three locations. An Urgent Telepsychiatry consult service was developed to support the Campbell River Hospital Emergency Department and Port McNeill Observation Room. By the end of the project, 226 consults were delivered to clients in remote and rural areas in the Island Health region. For those sites reporting wait times, the TeleMental Health Project reduced the average wait time for a consult down from 6-9 months to 4-6 weeks (a reduction of 700%). Very high levels of satisfaction were reported from providers, patients, clinicians, and primary care practitioners.

The success of the project generated multiple requests for Telehealth as a service option for mental health, sometimes putting a strain on operational resources. Expansion should be accompanied by dedicated resources and well-defined scope.

Technology in Practice – Seamless Communications for Improved Patient Outcomes

The highest quality outcomes for patients materialize when their care team – from the primary care home to their specialist partners – can maintain seamless communications. When the hospital was the meeting ground for all physicians, touching base in hallways and doctors lounges made these communications easier. Today, services are spread out in community settings and across geography. In rural settings geography impacts the ability for services to provide wrap-around care that is the norm in an urban setting. Reaching out to specialists, case conferencing with multiple services, and collaborating on care planning is challenging.

While telehealth is not a new concept to health care, the Kootenay Boundary specialists and family physicians are working with their Interior Health colleagues to build a comprehensive system for communications and relationship building across care teams through technology.

Piloted with tele-maternity (video conferencing for patients with their maternity provider) this
Shared Care project built the first in-office telehealth network between physicians. The success of this program sparked next phase work:
• The Mobile Maternity project funded by the Specialist Services Committee for obstetrics;
• Case conferencing in multiple sites for Child and Youth mental health;
• And the potential for rural patient education such as diabetes.

The other half of the physician network is a secure texting system for physician communications:
• contacting on-call specialists for triaging patients;
• accessing RACE specialists for clinical patient care;
• and hospital notifications to GPs on patient care.

Collaboration, communication and improved care team relationships are all impacts that are yielding improved patient outcomes. For maternity, patients have been saved hundreds of hours driving and improved safety. Reducing potential emergent problems for patients and improved physician relationships are documented successes.

Third-party evaluation is in place. Results from tele-maternity pilot are available, but the other systems are in initial phases without full evaluation complete.

Northern Partners in Care

Northern Partners in Care, a Shared Care initiative, aims to improve access to and quality of care across Northern BC by supporting specialist physicians (mostly in Prince George) to work more effectively with the family physicians spread throughout Northern BC. Working with specialist physicians from thirteen clinical areas, family physicians from many rural and remote communities, Divisions of Family Practice, Northern Health and others, Northern Partners in Care has identified and trialed and/or developed six enablers that support improved Shared Care in Northern BC. These enablers include enhanced use of telephone, outreach visits, videoconferencing, written communication, information technology and continuing professional development. There has been strong support for this work.

Through extensive consultation, trialing and development we have tremendous learning regarding the ‘mechanics’ and the benefits Shared Care. Our work is informed by best international practice in health system improvement, including quality improvement. By understanding the processes and infrastructure that support Shared Care, we have been able to deploy the enablers across clinical and geographic areas. Our evaluation aims to capture the Triple Aim, spread, sustainability and, more recently collective impact.

The presentation will provide a brief overview of the work of Northern Partners in Care then focus on one or two specific projects. Some of the challenges – which are in the areas of engagement of the many who support care processes (physicians and other), as well as technical issues and capacity issues – will be shared. Evaluation results of the projects focused on will also be shared.

C2: Youth Transitioning to Adult Services

Transition Care Management Plans to Facilitate Transition of Youth into Adult Health Care 

Background: Improvements in medical care have resulted in most children (98%) with low prevalence chronic conditions surviving to adulthood. For some conditions, e.g. congenital heart disease there are transition programs and consensus guidelines/statements. For others e.g epilepsy there is often a poor system in place to meet transition needs.

Objective: to provide 1)Condition-specific transition care management plans (TCMPs) to support transition care by ensuring access and attachment to adult healthcare providers. 2)For complex cases, a nurse navigator for patient and provider support.

Methods: Cardiology and Neurology were chosen as prototype specialties to develop TCMPs. Adult and pediatric specialists, allied health professionals and family practitioners were engaged to develop, disseminate and evaluate TCMPs.

TCMPs were divided into Role and Care Coordination, disease specific Patient Management and Lifestyle categories. TCMPs referenced best practice guidelines wherever possible and were developed with consideration of available provincial resources. TCMPs will be available on a web based platform.

A Transition RN supports providers for complex cases.

Results: Through an iterative, collaborative process 22 Cardiac and 6 neurology TCMPs are in development. The cardiology process involved 22 physicians including 15 cardiologists. Neurology TCMP development includes 16 healthcare providers (7 neurologists, 1psychiatrist). All plans involved an adolescent medicine specialist, family physicians, allied health and independent consultants.
The average TCMP required at least 3 revisions before initial testing and was 2200 words (range 1120-3270).

Evaluation: TCMPs will be modified following testing by specialists and family physicians through the use of standardized pediatric transition cases.\u2028
A TCMP guide book will be developed for scalability to other specialties.

The process of collaborative development of TCMPs between pediatric and adult healthcare provider builds relationships, defines the roles of providers and fosters trust, respect and accountability. It provides a forum to identify and remedy gaps in the transitional care process.

Youth Transition Initiative – Shared Care for Youth with Chronic Health Conditions


A new generation of youth with pediatric chronic health conditions and disabilities(CHC/Ds) are now surviving to adulthood. Ad hoc systems for pediatric transfer and failure to attach to adult care presents risks including increased mortality, morbidity, inappropriate emergency service utilization and expensive use of the adult healthcare system. \u2028The BCMA policy paper, Closing the Gap(2012), defined successful transition as “uninterrupted, coordinated, developmentally appropriate, and psychologically sound health care to young adult patients as they move out of pediatric care and into the care of an adult health care provider.” The Shared Care Youth Transition Initiative(YTI) addressed the following policy recommendations
1. Pediatric patients with CHC/Ds should have a family physician from birth. \u2028
2. Transitioning pediatric patients should have individualized transition plans. \u2028
3. Develop identification and tracking mechanisms to evaluate transition and long-term health outcomes. \u2028


The YTI (2011-2014) engaged prototype divisions of family practice, Family Physicians, pediatric and adult specialists and support staff to develop approaches for successful preparation and transfer of youth with CHC/Ds from pediatric to adult care, focusing on continuous attachment into adult care.

The triple-aim framework guided the development of transition protocols and tools.


• Medical transfer summary: To provide a relevant summary of pediatric history, anticipatory guidance, pertinent psychosocial information with electronic submission to physicians’ EMRs through provincial transcription services.
• Expedited referral process: To attach youth transitioning from BC Children’s Hospital(BCCH) to appropriate community care.
• Fee code recommendations: To appropriately reimburse physicians to support continuous primary care for youth with CHC/Ds. \u2028
• Tracking/evaluation algorithm: To identify transitioning patients at BCCH, thereby creating a regionally articulated provincial data set. \u2028


The YTI established the foundation to bridge gaps in transition for youth with CHC/Ds to adult community care. These processes and tools are available to be implemented in other provincial communities.

C3: Enhanced Recovery After Surgery

Enhanced Recovery After Surgery (ERAS) Collaborative: Local Lessons Learned through a Provincial, Surgical, Quality Improvement Initiative

The ERAS Collaborative seeks to build ERAS (Enhanced Recovery After Surgery) capacity in BC’s surgical programs. ERAS protocols are multi-modal perioperative care pathways designed to achieve early recovery after surgical procedures. Evidence supporting ERAS has been growing for 15 years, but the application of the pathway remains inconsistent across BC; as a result, complication rates for elective colorectal patients could be vastly improved.

The Collaborative Method
The Collaborative is a strategy for integrating evidence-based knowledge and innovation into practice. The ERAS Collaborative is composed of 11 multi-disciplinary teams from diverse hospitals, representing all regional health authorities. Over 14 months (November 2015-January 2016), our teams will have gathered at three Learning Sessions, and were supported during the Action Periods, when teams tested and implemented changes in their local settings between learning sessions. Teams were encouraged to use the Model of Improvement. The Collaborative ends in an Outcomes Congress.

The Collaborative developed a minimum dataset that is collected by all participating teams to monitor both site-level and collective progress and drive quality improvement. The dataset includes process measures reflecting the ERAS elements, as well as outcome measures. To date, the Collaborative has reached 80% compliance on 11 out of 19 pathway elements measured.

We will discuss how the Collaborative model can be an effective large scale, quality improvement tool and share our success factors and challenges. Royal Inland Hospital, Kelowna General Hospital, and Royal Columbian Hospital will highlight their results and lessons learned, including 1) a multi-disciplinary approach to developing an effective pre-printed order set that supports pathway compliance, 2) sustaining staff education, 3) different approaches to data collection, and 4) the value of team-building. We expect that our presentation will provide some ideas and lessons for other teams that are — or will be — implementing ERAS.

D1: Community Improvement

Improving Communications between Acute and Community

Many family physicians in Victoria have given up hospital privileges, concurrent with increased hospitalist-based care in urban hospitals. The resulting erosion of communication between settings affects the quality of patient transitions and health outcomes. While an effective hospitalization notification system exists, this alone does not create the conditions under which providers can communicate regularly or collaborate on care. To address this, we developed two pilots to determine the best method(s) of initiating communication between hospital and community, involving physicians, clinical and administrative staff in each setting.

Recognizing that communication needed to improve both to and from the hospital, our pilots tackled each direction respectively. First, we addressed the benefit of early notification about patient discharge from the hospital to the GP through a pre-discharge alert on one ward involved unit clerks contacting community GPs with an expected date of discharge. This provided GPs with advance notice, allowing them to potentially contribute to discharge planning. Secondly, we addressed the benefit of patient summary information being sent from the GP to the hospital through a pilot in the community involving 47 community GPs who agreed to fax patient summaries to wards after receipt of admission notification, to give hospital providers access to longitudinal patient information. We followed a quality improvement model that allowed for incremental improvements to the process during each pilot.

This presentation will report on current results, monitored through analyses of administrative data, surveys, and interviews with participants. A comparison of the methods will be used to discuss benefits of and barriers to communication as well as the question of who is responsible for ensuring that communication across care sites occurs. We will discuss the implications of these findings in terms of provider satisfaction and impacts on patient car weighed against the increased workload required to prepare and transmit information.

TEAM Based Care – A Best Practice for Patients & Providers

TEAM, or Team Enhanced Access to Mental Health Services, is a demonstration project taking place in Nanaimo BC, through an innovative partnership between Island Health and the Nanaimo Division of Family Practice’s A GP for Me initiative. The aims of the TEAM are to provide early and solid engagement with patients experiencing mild to moderate mental health challenges and who are currently not accessing centralized MHSU services, increase support for the Family Physicians who care for this population and to improve relationships between primary care and Health Authority delivered Mental Health services.

TEAM services leverage the expertise of three MHSU clinicians: a Psychiatric nurse, a clinical counsellor and a rehabilitation worker, all working under the direction of a Psychiatrist. The TEAM is situated directly in a GP office, breaking down the barriers many patients feel when accessing centralized services and increasing the ‘touch’ between GPs and mental health service providers. Physicians refer directly to the TEAM and have as much or as little contact with them as they deem necessary during the course of their patient’s treatment, which typically runs 6-8 sessions with the most appropriate provider.

Challenges to the new service include a slower-than-anticipated pace of referrals, space limitations in the clinic, information sharing between the Health Authority and GP offices and a mismatch between the patient population and the involvement of Psychiatry. Successes include anecdotal patient and GP experience, community agencies’ interest in referring clients and increased dialogue/relationship between GPs and MHSU. Evaluation measures include patient surveys, physician surveys, focus groups, key informant interviews and data collection on the patient base and referring physicians.

This project ties together patient need with physician identified gaps in service and a proven model of innovative, wrap around care. The model is replicable locally, better meeting the needs of patients and providers.

Physician Leadership in Advancing Social Determinants of Health

Evidence on the import and impact of Social Determinants of Health (SDH) in a wide array of chronic disease measures is unequivocal, and long standing. Physician understanding of these factors is strong, and growing. The number of physician’s who know what they can do about SDH is low. However, a small but committed group of GPs in the Division movement are working to change that.

In Kootenay Boundary, physician leadership in SDH has manifest in publication and distribution of The Poverty Intervention Tool, an evidence-based resource guide encouraging physicians in clinic to query their patients regarding financial difficulties, and take action based on local resources. The Tool was adopted from a similar resource developed by Dr. Gary Bloch and the Ontario College of Family Physicians.

In other jurisdictions, Divisions and individual practitioners are engaging in related efforts to mitigate the impact of SDH in health outcomes for their patients. These physician leaders, supported by Pacific Blue Cross, will be convening in the fall of 2015 to compare notes, and discuss how to broaden the impact of this work in a coordinated fashion.

At the Forum, following from the fall gathering, we look forward to discussing the wide spectrum of Physician-Led efforts to address SDH in BC, including the Poverty Tool.

D2: Adult Mental Health & Substance Use

Implementing CBT Skills, Group Medical Visits within Primary Care

The Shared Care Committee and the Victoria Division of Family Practice are funding local psychiatrists and family physicians to pilot Cognitive Behavioural Therapy (CBT) Skills Group Medical Visits as a new MSP-funded service in Victoria. This pilot project is in response to a series of consultations with psychiatrists, family physicians, and patients who highlighted GPs’ lack of capacity and comfort in serving mental health patients, in part due to insufficient education around mental health challenges and resources to treat effectively and efficiently within primary care. Family physicians and patients also noted the challenge of accessing affordable psychotherapy, particularly for patients with mild-moderate concerns. The purpose of the pilot is to (1) provide timely, publicly funded, evidence-based treatment in group format for mental health patients in primary care; (2) develop partnerships between family physicians and psychiatrists to facilitate the intervention, ultimately building capacity among family physicians to continue this service, (3) develop manuals and other materials to support sustainability of the service; and (4) establish a community-wide referral centre to ensure full-capacity groups and, thus, provider feasibility.

The CBT Skills Group Program combines CBT with acceptance-based strategies for adult patients who are suffering with mild–moderate or remitted depression and anxiety. CBT Skills Groups are composed of up to 15 patients led by family doctors and psychiatrists for eight consecutive weeks. Part 1 of the pilot includes psychiatrists and family physicians co-facilitating patient groups so family physicians can learn how to provide this service within their own practice. Part 2 of the pilot involves family physicians facilitating their own CBT Skills Group. Patient outcomes will be measures pre-post intervention on three outcome measurements (i.e., PHQ9, GAD7, and W&SAS). The pilot will also evaluate GP training needs, and community satisfaction with the service. Patient outcomes and preliminary evaluation results will be provided.

Patient Access to Care in Vancouver’s Downtown East Side

Vancouver Coastal Health (VCH) Pender Community Health Centre (CHC) provides primary care and addiction services to complex clients who live mostly in Vancouver’s Downtown Eastside. Team members include physicians, counsellors, and nurses that provide medication management, wound care and chronic disease management.. Drop-in starts at 1300hrs, and clients line-up at 1245 hrs to be seen. Clients continue to arrive and present for appointments until cut-off at 1500 hrs. Clients are seen on a first come, first serve basis and wait in the waiting room for the physician or allied health member to call for them and escort them to the examination room. The wait time ranges from 45 minutes to 3 hours due to complex patient population.

Patients using Pender CHC clinic are waiting 45 minutes to 3 hours to see a clinician, which is 50% more than the standard of 30 minutes suggested by the Institute for Health Improvement. Long wait times are exacerbated by clinicians pre-booking designated drop-in times. Finally, there is a lack of standardization to the patient journey through the clinic.

VCH Pender CHC and PSP partnered to reduce wait times by 25% for patients and to make the patient journey a more rewarding experience for all involved. We hope to increase patient and staff satisfaction, increase patient access, and clinic capacity, by utilizing LEAN, practice facilitation/coaching, project management and Trauma Informed Practice methodology.

Standardize patient intake process and expanded roles of staff. Implementation of a quality improvement huddle framework, review cycle time and office efficiency.

Evaluation of the change will occur in October 2015. Currently unable to provide results at this time.

Lessons Learned
• The value of iterative testing
• Role expansion leads to greater work satisfaction
• Build a system with reliable processes
• Integration of Voice of the Patient in care

D3: Access to Specialist Care

Improving Access to Cardiology Services through a Collaborative Model of ‘Shared Care’ 

Reducing wait times and improving patient access to cardiologists and cardiology services has been a key priority identified by the Vancouver Division of Family Practice. Through an iterative 18-month process, and under the guidance of the Doctors of BC Shared Care Committee, a working group of family physicians, specialists, patients, office assistants, and administrators designed a common referral and acknowledgment form that expedites the referral process and improves care.

The form allows family physicians the option to refer to either an individual cardiologist, or to any of the 30 outpatient cardiology clinics at Vancouver General Hospital and St. Paul’s Hospital. Concise clinic descriptions are provided and serve as an education piece for the referring provider. In addition, an embedded ‘acknowledgment of referral’ section helps to ensure a timely response is received within 3 business days.

40 family physicians and 20 specialists from Vancouver participated in a 3-month trial of the form and formal evaluation process has taken place. Initial results showed that 50% of family physicians and 54% of specialists reported an improvement to the referral process when using the form.

Challenges included arriving at a consensus among 30 cardiology clinics located at different sites to accept a single form in lieu of multiple existing ones. Another involved ensuring that the appropriate tests and relevant information are included in the original referral package. A third involved timely triage and acknowledgement from the receiving specialist. Despite these challenges, and thanks to the work of key clinical champions, use of the tool has improved communication among family physicians and cardiologists, for the benefit of patients.

Next steps for improvement involve integration of the form into the physician electronic medical record (EMR). Further consultation and opportunities for spread are also taking place within Vancouver Coastal Health.

North Shore GP – Orthopedics Initiative 

North Shore Family Physicians and Orthopedic Surgeons identified long wait times for orthopedic consultations, difficulty with timely communication, and an inefficient referral process as areas for improvement. Supported by Shared Care, we developed a centralized referral system, musculoskeletal screening clinic (ROCC – Rapid Orthopedic Consultation Clinic), and telephone advice line.

The centralized referral system introduced a standardized referral tool that could be triaged to the most suitable consultant along with proper investigations (medical imaging). Referral acknowledgements with wait time estimates were delivered to family physicians. Orthopedic surgeons (locums) and trained physicians conducted initial assessments in the ROCC and directed patients for the most appropriate non-surgical or surgical care.

The group also established a telephone advice line, where a dedicated surgeon discusses patient management with family physicians. This provides timely access to advice and avoids unnecessary referrals. A monthly average of 10 phone calls are received on the advice line.

From June 2013- May 2015, ROCC has received 5469 referrals. 74% of referrals were for expedited care, 10% indicated a specific physician, and 16% were redirected to the Joint Replacement Access Clinic. The new system has reduced wait times for consultation from 12–18 months to 3–4 months. 72% of patient survey respondents were very satisfied with their experience. Moreover, 94% of family physicians respondents expressed satisfaction with the screening clinic.

Following consultation, 18% of patients were referred to surgery, 20% to further medical imaging and 33% to other non-surgical services, such as physiotherapy, bracing and injections.
From the surgeons’ perspective, efficiency improved with 60% of their time spent seeing operative cases compared to 10% pre-ROCC. In addition to improved efficiencies, patient and provider satisfaction, and decreased wait times, there are also benefits such as avoiding unnecessary investigations, and family physician and ER visits.