Each breakout session at Champions of Change, hosted with the Joint Collaborative Committees, includes three presentations and opportunities to share successes, provide input, and learn from each other.
Wednesday, February 21 | 0900 – 1030
Wednesday, February 21 | 0900 – 1030
• RAPID FIRE
Primary care is centered on the face-to-face visit: provider and patient. Despite a digital revolution in methods of communicating, healthcare remains anchored to in-person visits, shackled by privacy concerns and antiquated billing policies. Though the quality of care is high and includes a physical exam, visits entail advance bookings, travel, sitting in a waiting room, and work absences. Many problems can be safely dealt with through alternatives when strong primary care relationships exist.
In spring 2017, the providers at Haida Gwaii Hospital & Health Centre (HGH) launched a pilot, where care is offered via a web-based texting application called Weltel®. Patients have the ability to text our Primary Care Nursing team for health advice and assistance. Registered patients receive an automated, weekly text asking “How are you doing?” Responses are categorized by a web-based platform and a nurse or nurse practitioner triages during weekday clinic hours. Responses are tailored to need and may include a text message, phone call, or an appointment with a healthcare provider.
We seek to understand how this service impacts health-related quality of life, the patient-provider relationship, interoperability and use of emergency services. Patient X was experiencing numbness in their hand. Via text communication, the nurse was able to rule out symptoms requiring an emergency visit and refer to a specialist. Our implementation strategy is unique to a rural and remote clinic; its launch is the first emergence of two-way texting in primary care nationwide.
At present, 5% of our patients are enrolled and all have used it. Users include teens, mothers, and grandmothers. The addicted, depressed, marginalized. Hypertensives, diabetics, and asthmatics. Texting shares results, books appointments, monitors symptoms and treatment, adjusts dosages, and offers advice to the worried and blue. Texting is bringing the clinic out of the clinic to where and when people need it.
In this workshop we explore emerging models of care enabled by virtual technology. In a world bursting with technology, patients are demanding not only prompt service, but also convenience of access for their health care. This includes the growing expectation that a patient’s primary care provider has immediate access to the information they need to provide a continuum of care no matter where the patient is – in a rural setting or an urban location. Our perception of the traditional models of service for patients is being challenged constantly and will not be sustainable.
This discussion will review new evolving models of care enabled by technology in Providence Health Care and the BC Interior led by the Kootenay Boundary Division of Family Practice: eCase or eConsult, Rapid Access to Consultative Expertise by phone or app, secure messaging, enotification and video conferencing in traditional and not-so-traditional settings (ICU, Mobile Maternity, PreSurgical).
These models are revolutionizing communications between specialists and family physicians – building relationships, providing clinical decision support, and opening access to different modalities of care – so patients have a continuum of care in their own community.
By exploring future models of care through technology we will:
• Present information from the patient and provider perspective on remote consultation services
• Delve into new models of care – eCase, RACE, secure messaging, Mobile Maternity, non-traditional telehealth
• Investigate the shifting value base related to virtual care – do our values match those of our patients?
The attrition of rural maternity services in BC is well documented, as are the consequent maternal-newborn outcomes for mothers who have to travel to access care. It is a provincial and professional mandate to support maternity care “closer to home” for rural women and their families, although this is not without challenges in low-volume and isolated settings. The Mobile Maternity project, funded by the Specialist Services Committee, set out to use technology to bridge the distance between rural women needing specialst obstetrical care and their provider but has expanded to include creating a virtual support system for care providers in low-resource environments. This latter application can been seen as one part of a larger systems approach to sustaining and growing rural generalist maternity services.
This presentation, based on our experience with the MOM project, will look at the use of telehealth in supporting rural maternity care and discuss its importance in sustaining isolated rural practices within the context of other system supports. Through a rural lens, we will consider the role telehealth has in enhancing generalist – specialist relationships, in being a conduit for continued medical, midwifery and nursing education, allowing specialist oversight in high acuity transport situations and other applications that strengthen the confidence and competence of isolated providers. We will conclude the systems perspective on the use of telehealth by reviewing tensions caused by its introduction and the implications on other parts of rural health care.
Wednesday, February 21 | 0900 – 1030
• RAPID FIRE
Physicians in the Kootenay Boundary Division provide care for 581 beds in 11 Residential Care facilities. The Kootenay Boundary Residential Care Initiative (RCI) MOU was among the first ones to be signed in BC in June 2015 and has transformed the manner in which we deliver residential care. Prior to the RCI, antipsychotics prescription rates in the Kootenay Boundary region were the highest in Canada, communication between physicians and facilities was challenging, and there was no formal forum available for GPs and facility staff to address issues. The KB RCI solution is based on collaboration and trust. We hold 14 regional and local-level in-person meetings every year. Through these meetings, which gather between 10 and 70 people, physicians, nurses, social workers, dieticians, pharmacists and facility managers have opportunities to connect, learn, discuss, and improve (QI loops). The meetings are safe and enjoyable, while focused on solutions. We compile data on 11 indicators from four different sources, including the GPSC Facility Survey, CIHI, and Interior Health. As a result of our work, we have achieved a 34% decrease in ED transfers, an 18% reduction in # of patients on 9 or more meds (with decreases in some facilities as high as 55%), and a 12% reduction in # of patients on antipsychotics without a diagnosis of psychosis. 83% of meeting attendees have indicated that they will change their practice as a result of the intervention. Our GPSC facility ratings have improved across the board, and are the highest within our health authority. In addition, we have created two resources on the Dementia Trajectory (now distributed widely across BC), and have shared our expertise (6 Divisions are currently using our data slide decks for 9 different areas in Interior Health). Next on our list is to individualize feedback for GPs. Our presentation will outline the strategies that we have utilized to bring physicians and facility staff together and improve our outcomes.
Innovative Tool Leverages Observations of Health Care Assistants to Reduce Emergency Department Transfers
Seniors living in Residential Care are at high risk of being transferred to an Emergency Department (ED). Some of these ED visits are avoidable if signs of health decline are identified early by staff and managed within the Residential Care home.
PREVIEW-ED© is an innovative tool designed specifically for Health Care Assistants (HCAs) working in Residential Care. Many tools used to identify the decline of residents in Residential Care focus on assessment by nurses. PREVIEW-ED© is an innovative tool designed specifically for Health Care Assistants (HCAs). Completed daily, it uses simple language, and an accessible format to leverage the observational skills and familiarity of direct care staff with the residents for whom they provide care. These observations may reveal subtle changes in resident health status which may indicate decline and provide an “early warning”. PREVIEW-ED© focuses on four of the main reasons why residents are transferred to the ED: Urinary Tract Infection, Dehydration, Congestive Heart Failure and Pneumonia.
Taking less than a minute to complete, the tool’s simple scale quantifies the change in health status, and provides a common language for team communication. The tool has been instrumental in improving communication and team functioning among care team members, and highlights the important role that HCAs have in Residential Care.
In 2016, a Fraser Health (FH) pilot in four care homes, demonstrated a reduction of ED transfers from Residential Care by 71% (n= 176). These results motivated Fraser Health to implement PREVIEW-ED© in all their 79 long term care homes. Results from this spread collaborative will be available in the fall, 2017 and will focus on ED transfers and other improvements. Preliminary results have shown improvements in team communication, and engagement of HCAs in resident’s care.
Every Voice Counts: Innovation and Persistence Results in First-of-a-Kind Residential Care Client Survey
The Office of the Seniors Advocate is an independent office of the B.C. Ministry of Health. The Office monitors and analyzes seniors’ services and issues in B.C., and makes recommendations to government and service providers to address systemic issues. Isobel Mackenzie, appointed in 2014, is Canada’s first Seniors Advocate. In 2016, the Office partnered with Providence Health Care to conduct a first-of-its-kind survey of residential care clients.
This in-person survey, through the efforts of over 800 volunteers over a nine month period, reached out to over 20,000 residential care clients across BC’s publicly-funded facilities. Survey collection wrapped up in April 2017, with high-level provincial and health authority-level results being released by the Office in September 2017. Detailed facility-level results will follow. Although a majority of residents have cognitive impairments, survey personnel made multiple attempts to complete the survey with each client, resulting in a 42% response rate. A parallel survey mailed to a client’s most frequent visitor has yielded over 9,000 responses.
Survey implementation and question design were informed by a consultation group comprising experts in gerontology and survey design, along with Ministry and health authority staff. Results will be analyzed in conjunction with clinical data from InterRAI assessments from B.C.’s publicly-funded residential care facilities. Survey results will dovetail with the Office’s annual Residential Care Quick Facts Directory to provide the public and policy makers with important data and findings. The Advocate will use the survey results as a road map to make recommendations for improvements in care quality.
Wednesday, February 21 | 0900 – 1030
• RAPID FIRE
Research, experiences of health providers and families, and information Canadians requested on the Canadian Virtual Hospice (CVH)’s Ask a Professional tool informed the need to develop an online grief support tool. MyGrief.ca is the world’s first evidence-based, psycho-educational tool to provide online loss and grief supports. The tools respond to a critical gap in bereavement services. It complements existing services and provides an accessible option for people who cannot easily access in-person grief support. A literature review and International development team of researchers, clinicians, and bereft family members developed MyGrief.ca. The modules cover topics from anticipatory loss, the nature of relationships between survivors and the ill/deceased, and challenges to navigating everyday life. Given the scope of the subject matter it was a challenge identifying where to draw the line for module content. KidsGrief.ca expands off of MyGrief.ca, It helps adults to recognize children grief, and provides them with well-informed grief support. It’s also a tool for educators, and health providers who are in a position to support young grievers or provide guidance to parents. Topics include: teachable moments, such as the death of a pet; preparing kids to be at the bedside of someone who is dying; informing kids about a death; and explaining Medical Assistance in Dying, and suicide. Both tools include text-based content and videos from actual grievers representing diverse age, cultural, and gender. The University of Victoria and First Nations University evaluation indicated that MyGrief.ca exceeded user expectations. Users indicated that it’s easy to navigate; includes high-quality information, easily supports existing university and volunteer education programs, and provides a sense of shared experience. Hosting and updating of the tools have been built into the CVH operating budget. Users accessing MyGrief.ca from outside of Canada are levied $25 USD for use.
Patients, GPs, and healthcare providers struggle to navigate the complexity of the current healthcare system. Patients are unable to receive proactive, responsive, and timely care, resulting in uncoordinated and fragmented services. GPs don’t know what services are available to support their patients, resulting in feelings of frustration. Staff feel unable to provide the best care possible because of workload concerns, budget constraints, and lack of clarity regarding roles and responsibilities. These circumstances discourage communication and trust, subsequently fostering a system of blame and disconnection. Fraser Health and the Chilliwack Division of Family Practice are co-designing a system of care that addresses these issues and moves to a patient centred, wellness focused model. The biggest changes will be how we work together, share information, and plan care together. Starting with our frail elderly and Home Health and Home Support, we will simplify their healthcare journey by assigning a community care team to a group of GPs. The team, currently an RN and LPN, closely monitors the GPs’ elderly patients with chronic diseases and uses a proactive approach to provide the right care in the right place. The first team launched in Jan 2017, second in Aug 2017, and more teams are on the horizon. By working with a small group of GPs and their patients, teams can identify opportunities to improve collaboration, e.g. charting directly in the GPs EMR. Benefits in the first 8 months: Improved communication; Rapid response to client needs; Reduced number of providers entering clients’ homes; Closer monitoring of conditions that leads to improved health (wounds heal faster & reduced ER visits); and Avoidance of hospital admissions. Our biggest challenge is how the leadership team can support staff to transition to a necessary change. We’re working closely with staff and Unions to ensure that staffs’ professional skills are supported and enhanced education provided.
Many patients at the Forensic Psychiatric Services Regional Clinics present with complex mental health and substance use needs, are transient and have difficulty maintaining housing, which increases their likelihood to be non-compliant with treatment. Patients who are non-compliant with treatment can potentially pose a greater risk of safety to themselves and/or others in the community. This project aimed to identify challenges and opportunities for electronic communications between patients/families and health care providers, to promote timely crisis management. Current policies advise against texting and emailing confidential information to patients unless the information has been encrypted and authenticated using encryption software. Patients, families and staff at the Forensic Regional Clinics were requesting the use of electronic communication because it is timelier, efficient, and supports those without a regular mailing address or home phone.
The project involved patients, families, the Forensic Regional Clinics, the Ministry of Health, and the Patient Voices Network. The initiative met a key requirement of Accreditation Canada that policies on the use of electronic communications and technologies be developed and followed with input from patients and families.
A baseline assessment of patients and families obtained a starting point to demonstrate how this project could deliver a tangible improvement. A Value Stream Mapping Session identified the pros/cons, barriers and constraints, and necessary policy recommendations. Patients were then surveyed about their preference for appointment reminders. In total, 31% of those surveyed preferred the use of electronic communication as their primary method for being reminded of upcoming appointments. The project results have informed the policy development and technology requirements at the agency and provincial levels to further support the usage of electronic communications.
Wednesday, February 21 | 0900 – 1030
• RAPID FIRE
A nurse can make a difference. In fact one nurse can change a system. At a time when the population is aging and home care needs are increasing beyond the ability of the health care system to manage them, we needed to make a change in how we work together between our GP providers and the HA specialized services.
The Fraser North West division of family practice began a revolution by hiring one nurse. Her name was Debbie. She in partnership with the family practitioners selected the most frail and at risk seniors to have proactive home visits to find out how they were functioning in the community and if there were any proactive supports needed. This extended the reach of the family physician to give a lens into the happenings and needs in the home and gave the patient one point of contact if there were concerns that they had. This nurse provided both case management and clinical supports to this group of over 500 patients
All of this was ongoing the health authority specialized team had just completed a review of the home health service to determine what was not working and the list was long. When they worked with the FNW division on how to improve the system they were oriented to the Nurse Debbie project and decided to look at those clients and determine if there was an effect on system utilization. The results were astounding. Over 500 ED visits averted and over 17000 patient days saved in the same cohort of clients within a 1 year period of introduction to this change in Nursing from a reactive to a proactive approach.
This started the redesign of the HH system for our region. We are now at a stage where positions have been changed to create an additional 16 Primary Care Nurses (Nurse Debbies) and 2 social workers. It is important to note that new dollars were not required for this change but a willingness to look at the system from a different perspective is. There will be many more steps along the way, but this will change our system.
Northern Health (NH) is one of the pioneering health authorities in BC to integrate Primary Care and Community Care services and implement team based primary care model. IPCC Resource Team is formed to support the Integrations work by 1) Developing and Implementing new processes for Primary Care Teams 2) Offering process related coaching to Primary Care Team members. The Team have approached the integration work from two angles: the technical side and the human side. The team employs QI and project management principles and tools to manage the technical side of the change to ensure that process changes result in improvements and avoid changing for the sake of changing. However, technical change is easier to design but will fail in implementation if people are not motivated to change or not supported adequately for change; i.e. the human side of change. The biggest challenge we face is changing the culture of the organization, “we have always done this way” and motivate and challenge front line leaders and clinicians to work differently and provide care in a team based environment. Instead of pushing down the technical changes to stakeholders, the team works with stakeholders to understand the sources of their resistance. Some resist the change because they do not believe the team based model will yield the result the health authority is looking for, while others believe in the model but lack confidence in the organization’s ability to manage the transformation process. Some resist the change because they are fatigued to constantly balance between change activities, new learning and day to day cares to clients. The team works closely with stakeholders to understand source of resistance and employ different strategies to manage the human side of change. Strategies include, phased approach to implement changes, involve stakeholders into solutions development to create engagement, provide communications regarding change, elbow to elbow coaching supports, etc.
Pharmacists in Primary Care increasingly rely on Electronic Medical Records (EMRs) to support quality patient care, reduce healthcare errors, and enhance appropriateness of care. Commercially available EMRs are not aligned with pharmacist logic or documentation needs for clinical and collaborative practice.
The Pharmacists Clinic (PC) at the University of British Columbia Faculty of Pharmaceutical Sciences has pharmacists working collaboratively with other health professionals to optimize patient outcomes. The PC invested in the design, modification, creation, and testing of 4 modules in the OSCAR EMR to enhance pharmacist contributions to health care teams: Medication, Disease/Indication, Healthcare Team, and Drug Therapy Problem tracker.
These modules were identified and prioritized from an analysis of pharmacist-best practices, patient needs in primary care and expanding scope of pharmacist practice; feedback from collaborating physicians, OSCAR EMR user groups and patients; and an environmental scan of other primary care practices across North America. An iterative 3-step process was implemented with final EMR changes published to OSCAR Canada.
The PC team has now used the new modules in the care of over 3800 patients for enhanced monitoring of patient clinical status, electronic documentation, patient-friendly documents, and standardized tracking of clinical metrics. New features include indication-based prescribing, patient-friendly disease synonyms, tracking of the patient care team for interprofessional collaboration and a drug therapy problem tracker to standardize monitoring of patient health outcomes and pharmacist workload.
The lessons learned to integrate pharmacist logic into a traditional EMR can also be applied to other health care professionals, laboratory services and specialist medical services.
Wednesday, February 21 | 0900 – 1030
• RAPID FIRE
The literature shows most hospital staff do not receive dementia education despite they care for patients with dementia in daily practice. Research tells us the gaps in success for dementia education include a lack of staff engagement, experiential learning, and sustainability. Workshops have limited effectiveness as staff often find the classroom content boring, not practical and difficult to retain. Many are unable to attend due to busy work schedules and staffing shortage. The goal of this project is to increase engagement, motivation, knowledge, and effectiveness of dementia education among hospital staff. This project involves a student in the BCPSQC summer internship program working with the clinical team and learning technology team in Vancouver General Hospital to develop an online learning module for a specific topic: Communication – The ART & SCIENCE of Person-Centred Care. The three phases of the 10-week project include: (1) literature review and needs assessment with users (hospital staff), (2) co-design of the content with 70 interdisciplinary staff (e.g., nurses, physicians, occupational therapist, physiotherapist, unit clerk) in medical and mental health programs, (3) testing the games in the learning module by using multiple PDSA cycles. The online course resides in the Learning Hub (previously called CCRS) where staff in all health authorities across BC have unlimited access to use. Staff not only gain communication skills in caring for patients with dementia individually but also can have fun and healthy competition as a social experience to stimulate ongoing engagement and active learning. In this presentation, we will demonstrate what we have learned about the impact of applying Gamification in Dementia Training (GDT). Findings related to improvements in knowledge and engagement will be discussed. We will engage conference attendees in dialogues about the acceptability and challenges in sustainability.
Cognitive Behavioural Therapy Skills and Group Medical Visits: Successes, Challenges, and Lessons Learned
In October 2015, the Shared Care Committee and the Victoria Division of Family Practice (VDFP) began an innovative pilot program providing Cognitive Behavioural Therapy (CBT) Skills group medical visits as a new MSP-funded service. Primary care providers had identified access to non-pharmaceutical mental health treatments as their top priority. The program responded by designing and implementing a self-management skills training program for groups of 15 patients. Family physicians facilitate 8-week series of 90-minute groups after being trained through co-facilitation and mentorship by psychiatrists. It has been a win-win-win story for patients, providers and local mental health services. Patients are referred to a central intake hosted by the VDFP, and choose a preferred group as offered by one of the 12 providers. To date, over 2600 patients have been referred from almost 400 Victoria family physicians and waitlists are minimal. Completers report 94% satisfaction, and nearly all participants would recommend the program to others. Self-efficacy is markedly improved, with 93% of completers reporting confidence in their ability to manage their mental health symptoms. Quantitative measurements of symptom severity have demonstrated statistically and clinically significant improvements, with large to very large effect sizes. Referring family physicians ranked the value of the program at 4.7/5, indicating that the program has had a positive impact on their patients’ mental health, increased access to mental health care, and has somewhat reduced the need to refer to specialist services. Providers of the groups, both psychiatrists and family physicians, report high levels of satisfaction and acceptability. Lessons were learned throughout the development, implementation, sustainability, and spread of the program with some recent learnings when spreading the program to new communities (i.e., Vancouver, Duncan) and patient populations (e.g., youth, women, cancer patients).
Vancouver General Hospital introduced a Peer-to-Peer Mentorship Program in March 2016 among the staff members of the ED. This project evaluated the effectiveness of the Peer-to-Peer Mentorship program in the ED since its introduction. Currently in the evaluation stage, close focus has been on the team dynamic, leadership engagement and overall culture of the nursing, physician, and allied-health team working in this busy, fast-paced ED.
This mentorship program was designed to introduce and reinforce leadership-based skills among ED staff. This involved providing focused educational and professional development opportunities regarding effective staff communication and teamwork both at the ED unit level and off-site. This level of involvement not only impacts staff satisfaction at work, but it also impacts the patients that they are responsible to care for, by influencing the quality of care that they are provided.
As our Canadian healthcare system strives to work towards improving quality of care for patients, it is therefore important to consider initiatives that address the interpersonal and leadership skills of the staff providing this care. This mentorship program has the potential to improve quality of care in the ED. Previous studies demonstrate that heightened communication and teamwork in the ED mainly impacts improving patient and staff satisfaction, reducing clinical errors and improving patient safety.
The objectives of the project are measured via semi-structured qualitative interviews with 11 nurses, 2 physicians and 1 champion (head of the initiative) who are all staff members of the ED and part of the Peer-to-Peer mentorship program. Afterwards, the transcripts are analyzed through identifying common and unique themes across the data. This information assists the researcher in further understanding the team dynamic, level of leadership engagement, and the overall influence of the initiative in the ED with recommendations for future development.
Wednesday, February 21 | 1100 – 1230
Wednesday, February 21 | 1100 – 1230
• RAPID FIRE
The Emergency Department (ED) protocol and accompanying tool, HEARTSMAP, were developed in response to growing concerns with the number of children and youth presenting in the ED in mental health and/or substance use crisis, and challenges faced with long waits, consistent assessment, and referral to appropriate support after discharge.
Addressing these challenges was the impetus for creating the ER Protocol Working Group of the CYMHSU Collaborative (a Shared Care initiative of Doctors of BC and the BC government).
The ED protocol consists of five clear steps and tools. Each step aims to inform a consistent, supportive approach in the ED for children, youth and their families in MHSU crisis, and to equip staff, many with limited mental health training, with the skills and confidence to support them. Communication and safety plans are also included to ensure information sharing among community service providers – including GPs – and to equip families to cope at home.
HEARTSMAP, developed by BC Children’s Hospital, is one of the key steps of the ED protocol, and was designed to address the need for a faster, and more accurate, consistent assessment of pediatric mental health issues in the ED.
The tool provides questions to allow practitioners to quickly assess a patient and make customized treatment recommendations, such as “consult psychiatry” and “refer to CYMH”, based on the outcomes of the test. Recommendations are personalized for each patient, so they are equipped with the information and community resources they need. The HEARTSMAP report is also used to develop the ER Protocol Communication Plan and Safety Plan at discharge.
The provincial implementation of the ED Protocol, and HEARTSMAP, are currently taking place at 30+ hospitals, and will be evaluated on its successful integration into clinical practice and effectiveness in providing more timely care, and referral to appropriate community resources.
In February 2017, we became the first ICU in BC to implement Releasing Time to Care – a front-line staff led quality improvement program. Lack of consistency in the storage of safety equipment was identified as a problem for the unit. The aim of the project was to improve patient safety and staff satisfaction by having new, unused safety equipment consistently at each patient bedside, while also reducing the costs and infection control concerns associated with having unneeded and possibly contaminated supplies at the bedside. This project is significant because it demonstrates how vital interdisciplinary collaboration is to developing and sustaining quality improvement initiatives. In consult with our nursing colleagues, as well as respiratory therapy, infection control, and housekeeping, we came up with a plan to modify how our safety supplies are stored in patient rooms. Two safety bags were created – one with respiratory safety equipment, and one with emergency medications. At patient transfer or discharge, the bags were kept intact, and wiped down by housekeeping. We measured time savings, cost savings, and compliance (i.e. presence of all safety equipment in the designated spot with no extra equipment) before and after our intervention.
Our data shows that the time to check the safety equipment decreased by 69%, the estimated cost savings are $13,087 for 6 months (cost of discarding all items with each discharge), and that compliance over time has remained steady.
One lesson we learned was how important interdisciplinary collaboration is to making any changes successful, especially in a critical care environment. Further, we found that establishing what we were going to be measuring before starting any interventions made it much easier to explain the value of, and progress of our project to our colleagues as we went along.
CONTEXT: For patients with chest pain, the target time from first medical contact to obtaining an electrocardiogram (ECG) is 10 minutes, as reperfusion within 120 minutes can reduce the risk of adverse outcomes in patients with ST elevation myocardial infarction (STEMI). In 2007, Vancouver Coastal Health (VCH) began tracking key indicators including time to first ECG. The Vancouver General Hospital (VGH) Emergency Department (ED) has had the longest door to ECG times in the region since 2014. In 2016, the VGH ED Quality Council developed a strategy to address this issue, with an aim of obtaining ECGs on VGH ED patients with active chest pain within 10 minutes of presentation. INTERVENTION: The VGH ED Quality Council brought together frontline clinicians, ECG technicians, and other stakeholders. Process mapping and root cause analysis determined two main barriers: access to designated space to obtain ECGs, and the need for patients to be registered in the computer system before an ECG could be ordered. The team identified strategies to eliminate these barriers, identifying a dedicated space and changing the workflow to stream patients to this space before registration. RESULTS: Our median times in patients with STEMI have gone from 33 minutes to 8 minutes as of June 2017. In all patients presenting with chest pain, we improved from 36 to 17 minutes. As of April 2017 we are obtaining an ECG within 10 minutes in 27% of our patients, compared to 3% in 2016. LESSONS: By involving frontline staff, and having champions providing real time support, we were able to make significant changes to the culture at triage. We cultivated sustainability by changing the workflow and physical space, and not relying on education. Implementing small changes and incorporating feedback has allowed us to identify new challenges early. While we have improved the times for our walk-in patients, we have not perfected the process when a patient moves directly to a bed or presents via ambulance.
Wednesday, February 21 | 1100 – 1230
• RAPID FIRE
The current fentanyl drug overdose death epidemic is the largest healthcare crisis in Canada today.
There were 956 overdose deaths in BC in 2016 representing more than 3X the total number of automobile deaths annually. The crisis is rapidly worsening with 1400+ deaths projected for 2017. More than 80% of patients who died in 2016 had prior medical encounters leading up to there death with the majority being in the ER.
Emergency Departments have an opportunity and obligation to think outside of the box of traditional ER care to proactively take steps to help these most vulnerable patients avoid overdose deaths. Opioid addiction is a chronic, frequently fatal disease presenting to emergency department acute care. Most opioid addicted patients need to use several times per day. Most previous attempts at intervention have failed as referrals to addiction services from community emergency departments do not show for appointment. The traditional ER focus has therefor been on treating complications of opioid use such as overdose, infectious, social and mental health complications. In July 2016 the BCCPS made changes to allow all physicians to use the opioid substitution medication Suboxone (buprophenone and naloxone in a sublingual tablet). This partial agonist is a safer treatment for withdrawal and ongoing substitution and has the best evidence behind it to help opioid use disorder patients recover from their disease. We aim to provide 100% of opioid use disorder patients presenting to Island Health emergency departments rapid access to addictions treatment and the option to use Suboxone to help them to achieve this. Piloted at RJH we partnered with community addictions clinics to standardize streamlined referral and Suboxone starts from the ER. Early learnings included the utility of nurse initiated referral, engagement of peer support organizations for patients and the potential for home Suboxone initiation… Culture shift in the ER is hard but necessary.
Background: As British Columbia enters its second year into a public health opioid overdose emergency, recent data show that BC First Nations communities are disproportionately represented in rates of overdose and overdose deaths.
Objectives of the research project: The Indigenous Wellness Team (IWT) at the First Nations Health Authority has created workshops to host conversations with BC First Nations communities that support culturally safe and culturally relevant conversations around harm reduction and addictions through an Indigenous lens.
Methods: Culturally relevant workshops were designed including “Indigenizing Harm Reduction”, “Decolonizing Addiction”, “Take Home Naloxone” and “Indigenous Perspectives on Healthy Sexuality”. New learning models were also developed: “Indigenizing Harm Reduction Learning Model” and the “Sexual Wellbeing Model”. These incorporate traditional Indigenous knowledge systems that are rooted in teachings around intergenerational strengths and resiliency.
Results: From May 2016 to July 2017, the IWT hosted 52 workshops throughout B.C. There are now 84 Naloxone dispensing sites and 126 First Nations communities have been trained in Naloxone and rescue breathing.
Conclusions: Indigenizing harm reduction and creating new learning models focusing on culture and intergenerational strengths, are effective ways of sharing and exploring teachings around harm reduction with BC First Nations communities.
From 2015 to 2017, The BC Practice Support Program has delivered learning sessions surrounding Pain Management to hundreds of GPs in the province. Evaluations methods have confirmed benefits in increasing physician confidence in their pain management techniques, including opioid prescribing.
our storyboard will display some of the survey results from GPs surveyed after the learning sessions.
Dedicated paid time enabled very busy GPs to build more capacity and efficiency and clinical certainty in their management of chronic non cancer pain. In consideration of how many opioids in our community are prescribed by GPs in BC, the potential benefits of this program should be highlighted and expanded upon.
As BC was a world leader in guideline development for prescribing of controlled substances, the PSP program in its iterations can be seen as a world leader in adult education in this very topical area of medicine.
Wednesday, February 21 | 1100 – 1230
• RAPID FIRE
The “Healthy Medication Use Initiative – Medication Management in First Nations Communities,” is a collaborative project established in 2016 between the First Nations Health Authority, University of British Columbia Pharmacists Clinic, First Nations communities, and community pharmacists. This is a community-driven initiative with the objective of supporting the design and delivery of pharmacist-led clinical services in First Nations communities in British Columbia (BC). To date, 40 of the 205 BC First Nations communities have received funding to participate in this initiative, with 22 community partners and pharmacists actively engaged with the UBC Pharmacists Clinic in service delivery. As a community-driven initiative, First Nations communities are responsible for determining the pharmacist(s) who will be participating. Pharmacist-led clinical services include one-on-one appointments for medication management, educational presentations and patient workshops. Implementing this initiative highlights the need for a scalable community-driven approach to identifying needs and priorities for pharmacist-led clinical services. In addition, common enablers and barriers have been identified for pharmacists in providing care in First Nations communities. These lessons have the potential to inform not only the future of this initiative, but other projects across Canada involving First Nations peoples, pharmacists and other health care professionals. Despite ongoing efforts, health disparities between Indigenous and non-Indigenous populations in Canada remain. Pharmacists contribute a unique drug-therapy perspective and can play a key role in improving the health and wellness of Indigenous patients. To our knowledge, current literature is lacking in its’ exploration of the role of a pharmacist in Indigenous health.
In the wake of the Truth and Reconciliation Commission, non-Indigenous health care employees are increasingly speaking up against racism towards Indigenous people in their organizations. This is an arduous task, and employees need an opportunity to build their capacity in responding to institutional racism. At Island Health, several non-Indigenous staff working to advance Indigenous Cultural Safety approached the Indigenous Health team for guidance on how to engage their colleagues in critical conversations about issues related to Indigenous-specific racism. It became clear that a supportive space was needed for non-Indigenous staff to examine their role in responding to these dynamics.
A partnership was struck between Island Health and the Provincial Health Services Authority to find an innovative way to provide support to staff. The partnership resulted in the establishment of a Non-Indigenous Settler Community of Practice; a facilitated discussion group designed to bring together non-Indigenous Cultural Safety Champions to critically examine the issues that surface when trying to advocate for safer services for Indigenous people. The group was comprised of 10 non-Indigenous staff working in various parts of the system at Island Health. They met face-to-face over a 10-month period to discuss topics such as systemic racism, white privilege, settler privilege and colonialism, and to explore how these processes show up in their work.
An outcome evaluation and observations from Indigenous staff demonstrated that the Community of Practice contributed to transformative learning experiences that promoted profound changes in staff behaviour and practice. These changes included increased confidence among non-Indigenous employees in speaking out on racism and decreased anxiety among Indigenous staff in the workplace. Presenters will share these lessons and provide tips for starting similar groups in health care settings.
Colonization is recognized as a root cause of health inequities experienced by Indigenous people in Canada. The health gaps between Indigenous and non-Indigenous/Settler Canadians is further exacerbated by ongoing institutional racism and discrimination towards Indigenous people, as well as colonial ideologies that are deeply embedded in our healthcare system today. As a result, when Indigenous people access health services they often ironically experience harms in the form of prejudice, stereotyping and bias, which contribute to further access barriers.
The PHSA San’yas Indigenous Cultural Safety training program was created as an intervention to promote culturally safe practices among healthcare employees. In the San’yas training, participants are asked to discuss examples of Indigenous-specific stereotyping and discrimination. Through this intervention, San’yas participants have collectively provided thousands of examples of Indigenous people being stereotyped and harmed in the healthcare system. This narrative data provides a glimpse into the harms that Indigenous people experience on a daily basis when trying to access health services.
With the aim of deepening an understanding of stereotyping harm and how racism plays out in health care, a mixed methods study was designed to analyze this data and provide insight into ways of promoting culturally safe organizational practices and improving quality of care for Indigenous people. A Qualitative Inquiry approach was used to undertake a thematic analysis of the narrative data and measure frequencies of recurring themes.
Results from this analysis will be presented, including preliminary findings on the where harm tends to occur within the health system. Insights will be shared on how Indigenous cultural safety training can play a key role in an organizational framework to address Indigenous-specific racism, contribute to transforming workplace culture and improving quality of services.
Wednesday, February 21 | 1100 – 1230
• RAPID FIRE
In the absence of red flag symptoms, there is no evidence of utility of advanced imaging in patients with significant osteoarthritis (OA). A new protocol was introduced at two acute hospitals in Vancouver Coastal Health where patients were assessed for advanced OA before proceeding to advanced imaging (MRI and CT arthrograms). In 2014 the study sites completed 836 MRI for the shoulder, hip, or knee for outpatients over 55 years of age; this population is at increased risk of co-existent OA.
The new protocol, introduced in October 2016, required recent radiographic images (acquired within 1 year) to be appended with the advanced imaging order for hip, knee or shoulder for patients over 55 years of age. The radiologists reviewed the images and graded the degree of OA using a validated tool, the Kellgren-Lawrence (KL) scale. In patients where the KL score >2, significant OA is present and advanced imaging was not approved. Significant workflow changes from community-based referring physicians, radiologists, and clerical staff were required to successfully implement the protocol.
We applied the Model for Improvement to the project. The first PDSA cycle highlighted workflow issues for clerks and radiologists. Value stream mapping helped identify value added and non-value times in the process. After several PDSA cycles on the workflow, processing time decreased from 57 to 15 days for the new protocol, as compared with a regular MRI booking process that would take 3 days. Nevertheless, the rejection rate was 38% as a result of avoiding unnecessary exams.
The two takeaways to share are: how continued involvement from clerks and radiologists is needed to collect data and generate ideas to eliminate non-value added delays; and the robust measurement process required to assess effectiveness of the implementation and the impact on referring orders. Such lessons are likely to be pertinent to other outpatient quality interventions, especially in lab and medical imaging.
In June 2017, the Canadian Foundation for Healthcare Improvement in partnership with the College of Family Physicians of Canada, Canada Health Infoway and the Royal College of Physicians and Surgeons of Canada launched the 15-month Connected Medicine Collaborative. This work supports 11 Canadian teams to focus on designing, implementing and evaluating a remote consult service to enhance primary care provider communication with specialists with the long-term goal of improving access to specialty care for patients. The collaborative focuses on spreading two leading Canadian innovations that have demonstrably improved primary healthcare access to specialist consultation: 1) Rapid Access to Consultative Expertise (RACETM) – a telephone consult service from BC and 2) Champlain BASE eConsult Service (BASETM) a web-based eConsult service from Ontario.
Many programs fail to realize their potential in “real world” settings as the evidence supporting their effectiveness often does not account for local contexts, which can be crucial to successful replication. This is especially true of eHealth solutions. Neglecting this can result in costly failures, which have been demonstrated in many health systems. Having a focused learning collaborative can facilitate successful adoption, while building improvement capacity within the system.
Now at the half-way point of the collaborative, this session will highlight the featured remote consult innovations being led by the 11 teams. It will showcase implementation approaches, lessons learned and early results on the journey towards improving the quality and experience of care for patients and providers while building organizational proficiency and capacity in quality improvement and change management. The session will also shed light on some of the challenges teams have encountered and strategies used to overcome them, while ensuring sustainability and scale-up of their innovations post-collaborative.
In 2008 BC created a nurse (RN) staffed telephone triage service (TTS) to provide timely advice to 811 callers. A perception exists that some callers are needlessly directed to emergency departments (EDs). We sought to determine whether supplementary emergency physician (EP) triage would decrease ED visits while preserving caller safety and satisfaction. TTS RNs use computer algorithms and judgment to triage callers. Potentially sick callers are directed to “seek care now” (red calls). Often this is to an ED depending on acuity and time of day. In VCH from April – September 2016 between 8:00 – 24:00 hours, a co-located EP also spoke with “red” callers to provide further guidance. Callers were followed up within 1 week and satisfaction was evaluated on a 5-point Likert scale. The TTS data was linked to the VCH ED database to assess ED attendance within 7 days, and the provincial vital statistics database for 30-day mortality. Our primary outcome was the proportion of unique “red” callers who did not attend the ED compared with a historical cohort one year earlier without EP triage in place. In the study period there were 5105 “red” calls of which 3440 were transferred to the EP (67.4%), 2958 of EP assessed callers (86.0%) had a family doctor, but only one-quarter of such patients could contact their family doctor. Overall, 2301/3440 “red” callers did not attend an ED (67.0%) compared to 2508/4770 in the control period (52.6%), for an absolute reduction of 14.4% (95% CI 12.2 to 16.4%, p<0.0001). In callers for those < 17 years old there was a 20.3% (95% CI 16.5 to 24.1%) reduction in ED visits compared to the control group: 771/1520 (50.7%) vs 364/1067 (30.4%). There was no difference in 30-day mortality between groups. Age and acuity were also similar between the two groups. Mean caller satisfaction was excellent (4.7/5.0). EP supplementation of a RN advice service has the potential to reduce ED visits by almost 15% while providing excellent safety and satisfaction.
Wednesday, February 21 | 1100 – 1230
• RAPID FIRE
The objective of Fraser Health’s Integrated Plan of Care is to have a single, accessible electronic health record using the MEDITECH Patient Care System (PCS) module to document an individualized and integrated plan of care for all professionals involved in a patient’s care. The objective of Fraser Health’s Integrated Plan of Care is to have a single, accessible electronic health record using the MEDITECH Patient Care System (PCS) module to document an individualized and integrated plan of care for all professionals involved in a patient’s care.
Abbotsford Regional Hospital was the first site in Fraser Health to implement the PCS module successfully on November 1st, 2016. The PCS module allows the clinician (nurse, allied health, and support personnel) to complete point of care electronic documentation and creates a unique person-centered view of the patient’s health information across the continuum of care. This system was designed to provide an integrated approach to improve the flow and sharing of information between care providers by allowing for timely data capture, improved data quality, consistent documentation, embeds clinical decision-making tools, reduces redundancy in documentation, and supports timely clinical decisions, thereby enhancing the quality of patient care. Due to the transformational nature of this change, we need a different approach than the typical way we implement technology-related projects.
This rapid fire presentation will share:
1. An overview of the project
2. The secret to our transformation success: Changing the way clinical, technical, organization readiness and functional readiness teams worked together with clarity and alignment regarding change delivery to enable more effective management to outcomes.
3. Our measurement approach: How we defined, monitored and measured the people side of change using Prosci’s Change Scorecard, a powerful combination of outcome and activity measures in three dimensions and timeframes.
4. Our results.
Most importantly, take away practical insights for measuring complex change in any organization.
Island Health does not have administrative oversight or a structured process for approval of Quality Improvement (QI) projects. QI is largely conducted within program areas and there is no requirement to obtain administrative or ethical approval. Consistent with ethical conduct of the Tri-Council Policy Statement, best practice suggests that QI does not require the same level of review as a Research Ethics Board, but should receive supervision similar to that required by clinical practice (Morris & Dracup,2007). There is an increase in physicians/staff pursuing QI work. With no structured process, Island Health is at risk if QI projects result in harm to patients or staff. In particular, QI activities involving vulnerable populations should require higher level consideration of risks and impacts. Some teams may not be comfortable or experienced in applying an ethical lens to their QI work, potentially limiting their ability to mitigate associated risks. Through a multi-phased approach, Island Health is trialing a rapid response ethical consult process. This began with the adoption of the Alberta Innovates ARECCI tool to assess project risk and differentiate QI from research (Phase1-ARECCI). Based on the ARECCI score, Research & Quality collaborated to provide proportionate consults, ranging from brief phone calls to interdisciplinary meetings that identified risk mitigation strategies (Phase2–CONSULT PROCESS). The ultimate goals are to: 1) marry this consult process with a formal registry to track QI projects in the organization for the purposes of learning and 2) implement a policy on QI ethics and oversight which aligns with the developing organizational ethics framework (Phase3–INTEGRATION & LEARNING). We want to share our learning and facilitate a provincial dialogue about applying ethics to QI. Many health authorities are experiencing the same dilemmas, and although the trial will be in progress, we expect to have preliminary evaluative data to share at QF2018.
As communities in the province implement the Patient Medical Home / Primary Care Network, evidence from review of success literature in other jurisdictions emphasizes the critical importance of quality improvement (QI) with respect to actually achieving triple aim goals. Without robust QI, we believe the PMH/PCN transformation in BC will fail to achieve its promise of contributing to a sustainable health system. If we are not actively measuring the results of our efforts and engaging in routine discussion regarding outcomes, changes we make may not be improvements.
Accordingly, in the Kootenay Boundary CSC’s PMH/PCN proof of concept in the Boundary Region of BC, extensive work has gone into designing and implementing a robust QI framework. Rooted in five system-level key outcomes relating to acute care utilization, and tracking nine PMH-level indicators, including sub-sets for patient experience, time to third next available appointment and team functioning, the Boundary QI process will regularly involve every member of the GP and Health Authority Team in meetings to discuss data and review outcomes. Kootenay Boundary is placing a “big bet” on the ability of data and indicators to motivate clinicians and administrators alike to change behaviours for the benefit of patient care.
Join us for an overview of our QI plan, “battlefield” stories of the first few months of proof of concept implementation, and discussion regarding how our earliest data points are influencing care.
Wednesday, February 21 | 1415 – 1545
Wednesday, February 21 | 1415 – 1545
• RAPID FIRE
CONTEXT AND RELEVANCE: Expanding upon the already well functioning and well established unilateral knee replacement procedure at White Rock Orthopaedic Surgery Centre (WROSC), an outpatient facility, we aim to have same-day-discharge for Total Knee Replacement (TKR) at our clinic in order to reduce hospital stay, patient complications, costs, and give the patient faster and more personal care. We emphasize our specialty and great success in TKR patients with the importance of continuity of care, pre-and post-surgery, with a designated nurse for care and Case management, available 24/7. Our success has not only been on the operating table, but at home too. INTERVENTION: Dr. Arno Smit is committed to the program and would be a champion of this progress. Patient selection is the first and most critical clinical consideration. We emphasize taking a highly individualized approach to anesthesia, pre-operative evaluation, multimodal, non-narcotic anesthesia, and highly motivated patients that are relatively healthy. Between November 2016 and February 2017, 10 candidates out of 24 have been enrolled for TKR.
The process includes pre-operative preparation: surgeon, clinic nurse, home care nurse (2 hours), Physiotherapist (2 hours), Pharmacist. Dr. Smit on average does his total joint replacement between 45-60 minutes. MEASUREMENT: Qualifying criteria is based on individual pre-op assessment, patient’s current health, ASA score, BMI, and home environment. We have very clear pre–op and post-op written instruction. The clinic nurse will be responsible for a thorough discussion and teaching of each patient undergoing the day surgery in WROSC. Patients will know what to expect and are given a pain score/comment card to fill out for their entire experience. Results: 0/10 pain score for all 10 TKR patients. EXPERIENCE: outpatient total joint program reduces pain, costs, and speedier recoveries.
Pacemakers (PM) are life-saving devices used to care for patients with symptomatic bradycardia. In British Columbia (BC), regional variability exists with implant rates, device types used, and quality of care delivered. As such, Cardiac Services BC (CSBC) and physician leaders have embarked on a 3-year quality initiative to improve care for PM patients in BC. Process mapping, review of protocols and patient materials and identification of the intraoperative team skills, roles and comfort level was completed for 13 different implanting sites. A provincial outcomes review was completed in 2016 and included the assessment of 27,556 adult PM procedures (2008-2014). Reported at the provincial, site and operator levels, outcome indicators included: 30-day, 1 and 2-year repeat procedure rate, 30-day all-cause hospital readmission, 30-day and 1-year mortality, and 30-day device-related complications. Variability existed among all sites with respect to: referral management, intraoperative team composition and training, use of protocols and checklists, OR availability and patient discharge education. The 30-day repeat procedure rate was 2. 5% (0.7-6.6) and increased to 4.6% (1.8-10.4) at 1-year. Kaplan-Meier analyses (4-year follow-up) revealed that the majority of repeat procedures occurred within the first 60-days following a new implant and were predominantly lead related. After-hour procedures (18. 2% of BC procedures) were associated with a 30% increased risk of requiring a repeat procedure. Variability is expected in a decentralized system that serves different geographical regions. Findings exemplified the need for a provincial quality improvement initiative designed to: promote evidence-based patient and device selection, strengthen the clinical network, standardize implant techniques, establish OR team training requirements for PMs, improve operational logistics, and standardize patient resources and data collection methods, including patient reported complications.
The Minister of Health committed to increasing MRI volumes to address wait lists, and asked BC health authorities to implement Choosing Wisely (CW) guidelines for medical imaging. While helpful in defining appropriate use there remain inherent inefficiencies through siloed booking processes and limited opportunities for decision support. Historical de-centralized booking also contributed to inappropriate and even redundant imaging orders that burdened the healthcare system.
In partnership with PATHWAYS and Lower Mainland Medical Imaging, educational decision support tools will continue to be developed and made available for referring physicians. PATHWAYS is an online resource that allows GPs and their office staff to quickly access current and accurate referral information, including wait times and areas of expertise, for specialists and specialty clinics. It has launched with 25 Divisions of Family Practice covering approximately 4000 GP members. To help motivate referring physicians to review these resources, we will trial providing imaging test wait times on the PATHWAYS site allowing referring physicians to understand regional disparities and to make informed decisions around test ordering and the site they will choose to refer to.
While we believe that this will meaningfully improve test selection and somewhat homogenize regional waitlists, we will concurrently seek imaging protocol homogenization to enable centralized booking for certain core tests. This is something that has been sought by referring general practitioners for some time but has not been available owing to the heterogeneous scanning protocols across sites.
Through this multipronged approach of increased process and waitlist transparency coupled with increased educational outreach and streamlined MRI booking, we aim to significantly improve the experience of the patient and referring physician while eliminating duplicate requisitions and enhancing appropriateness.
Wednesday, February 21 | 1415 – 1545
• RAPID FIRE
Metabolic syndrome, including diabetes, is an enormous problem for Canada. A recent Alberta study forecast that anyone born after 1997 will have a 50% chance of developing type 2 diabetes in their lifetime. For indigenous peoples, the rate was 80%. ‘Personalized therapeutic nutrition’ is an individually tailored nutritional intervention designed to reduce or reverse patient specific metabolic dysfunctions, medical conditions or associated symptoms. Evidence-based clinical applications for therapeutic nutrition are extensive: metabolic disorders, inflammatory conditions, neurodegenerative diseases, psychological conditions, and cancer. The more we learn about what genetic and metabolic factors determine why some people respond to a certain type of diet and lifestyle intervention, while others do not, the more powerful a tool personalized therapeutic nutrition will become. The public is way ahead of our health care system in choosing a ‘food first’ approach, but many need help discerning the scientific quality of nutritional information they access. They also face safety issues if medications are not adjusted to reflect improved metabolic function. Health professionals are challenged to keep up with new research and practices on therapeutic nutrition, and most haven’t learned how to effectively support this approach. The Institute for Personalized Therapeutic Nutrition (IPTN) is closing the research-practice gap by translating evidence into educational programs for healthcare professionals to support practice change and advocating for therapeutic nutrition as a fundamental and required aspect of patient care. The IPTN is also conducting a proof-of-concept clinical trial with 200 subjects, seeking to demonstrate the clinical impact of food-based therapies. During this session, we will describe the genesis of the IPTN, present interim outcomes from our projects, and propose a future vision for personalized therapeutic nutrition and a ‘food first’ approach to health.
For years, BC Children’s Hospital has been facing increasing demands for ambulatory clinic services with limited resource increases. The Cleft Palate & Craniofacial program is no exception to this challenge. Specific issues heightened the need for a detailed review and quality improvement project. These issues included: excessive number of patients who had exceeded the recommended timeframe for follow up visits, challenges in meeting standards of care, staff workload issues and patient complaints and feedback.
Over 600 chart were reviewed assessing actual clinic care provided against published standards and specific patient recommendations. The existing referral, triage and waitlist management process was conducted to review current practice and develop a new model of care. A demand vs capacity analysis indicated that demand was exceeding supply by two thirds. In addition, to the demand/capacity gap other challenges included clinic flow optimization, desire for a formal transition pathway, the need to empower families to be Partners in Care and better liaison with community care givers as partners . Quality recommendations and improvements have been outlined which are anticipated to support 1/2 of the demand with a business case created to support the remaining 1/2 of demand. The next phase of work will rely on an implementation team to work on the redesign of the clinic. One of the greatest benefits from this work was the strong relationship and trust that was formed between the clinical team and management team. The project plan and processes used for this clinic review will serve as a model across all of the BC Children’s Hospital ambulatory clinics with the continued goals of improving patient access, improved management of resources and improving the quality of care.
This project highlights engagement, demand/capacity analysis, project management and process improvement.
Context and Relevance:
The Campbell River Hospital (CRH) has been a referral centre from surrounding communities for years. A woman in labour might arrive in Campbell River having driven 2-3 hours, or having taken a ferry, or having taken a boat… or all 3!
A group of family physicians recognized significant barriers to antenatal care; particularly geographical considerations for women from remote and First Nations communities and high numbers of local “unattached” patients.
In 2014 the CR Maternity Clinic began antenatal visits in Port Hardy, to reduce the travel for women intending to deliver in Campbell River. In late 2015, Island Health and First Nations Health Authority joined forces with the physicians to open a clinic at CRH, providing ready access to maternity, radiology and laboratory services.
multiple small PDSA cycles to try things without specific funding –a hospital based clinic one half-day per week led to funding for a 10 week special project, identifying a need and sustainment through Island Health.
process mapping to solve some problems ensuring results in the EMR .
existing resources in new ways, including the booking of follow-up appointments, reducing the number of “no shows.”
patient interviews and exit surveys to determine how our processes are being received.
The clinic has grown to 4 half days/week. Visits to Port Hardy continue once/month. A telehealth project “MOMS 2” has been initiated in 2017.
Since Nov 2015: over 3000 patient visits; women and families from 25 communities. First Nations women and babies: 25% of visits in the CRH clinic; 60% in Port Hardy. Cultural safety and humility have been a focus since day one. Feedback surveys report patient satisfaction with accessibility and care provided.
The funding! Numerous parties including the CRH Foundation, Division of Family Practice, IH and FNHA have collaborated to acheive a “grass roots, local solution.”
Wednesday, February 21 | 1415 – 1545
• RAPID FIRE
In the eastern, rural area of Fraser Health (FH), Hope and communities of the Fraser Canyon have a strong sense of community belonging and many attractions to live, work, and play. However the geography poses challenges of rural service provision, access, and isolation. My Health My Community survey and other data confirmed what the local community knew: people here are experiencing decreased health status, including higher rates of chronic disease and smoking, shorter life expectancy, and lower socioeconomic status.
In 2016 FH launched a novel approach to address these issues by asking “What do YOU see as the priorities to improve health and well-being?” The entire community was engaged via forums and online, and their priorities were met with a $500,000 annual FH investment. This Hope Health and Well-being initiative includes funding 6 new Coordinators for Healthy Living, Youth, MHSU, Volunteers, Health Services, and Transportation. Micro and Macro Health Grants offer seed funding and propel ideas with broader community impact. So far these small investments have had a big return- AdvantageHope completed an active transportation plan and acquired a $500,000 grant; District of Hope secured new transit service; and Micro grants funded a parental wellness circle, playground, exercise space, food security, and community theatre to name a few.
Though in early implementation and evaluation, we know from people like Wayne that this community-based approach is already making a difference. Wayne lives in Hope and after reconstructive shoulder surgery, he often drove 110km roundtrip to Chilliwack for rehabilitation. After a Micro Health Grant funded rehab services, Wayne was able to see the same physiotherapist in Hope, which was “great advantage as far as travel time and expense as well as convenience”.
We know it takes a village to raise a child, and we have learned it takes a community to promote wellness and establish a truly community-based system of health.
In December 2016 RainCity Housing (RCH) was invited to partner with Vancouver Coastal Health (VCH) in order to provide unionised Peer Specialist (Peer) services on 6 multi-disciplinary DTES teams. This role was one of a number of service improvements that were identified as part of VCH’s 2nd Generation Strategy, which is aiming to improve the system of care in Vancouver’s Downtown Eastside neighbourhood. The integration of Peers onto our care teams aims to increase social inclusion and attachment to care for clients, many of whom have significant histories of trauma and negative perceptions of clinical healthcare interactions, as well as to provide valuable insight to DTES healthcare providers regarding better practices of approaching clients in a collaborative and community-minded way. RCH has background in the grassroots of the DTES and a long history of Human Resource practices which value voices of lived experience, including the development and implementation of multiple Peer and Indigenous Cultural Liaison positions on internal staff teams. Evaluation is ongoing, and a 1 year report compiled of surveys and qualitative interviews with VCH clinical staff, RCH peer specialists and clients of DTES teams is expected for Spring 2018. Many learnings have already become apparent, including the value of the health authority/non-profit partnership to provide adequate support to both Peers and VCH teams, the need for well-defined job descriptions and roles/responsibilities of Peer Specialists on Clinical teams, the difficulty of culture shift between a non-profit support work focused workplace and a clinical setting, and the need for culturally appropriate supports and job-descriptions for Indigenous Peer Specialists. We hope to present on these learnings in a narrative style, and invite two of our Peer Specialists to co-present in their own voice.
Testing a ‘Wraparound’ Model of Care in a Rural Setting for the Complex Child & Youth Mental Health & Substance Use Community
More than ever, mental health and substance use concerns touch our communities, friends and families. Perhaps, we are a more aware society with better diagnostic tools and a greater desire to deal with these challenges. Whatever it is, we are seeing more children and youth in the West Kootenay region struggle with mental health and substance use challenges. Parents are faced with the stress of dealing with a complex support system while trying their best to create and maintain a loving supportive environment for their children. Like many small communities, the barriers to receiving timely and integrated mental health and substance use services in our region include wait lists for services, lack of coordination of services, and communication issues between service agencies. In order to address part of this problem the Child & Youth Mental Health and Substance Use (CYMHSU) – West Kootenay Local Action Team (WK LAT) conducted an eight month Wraparound Prototype across the region.
This presentation will share the activities undertaken by the WK LAT to test a Wraparound Model of Care which engaged over 45 service providers and two school districts, and utilized two wraparound coaches to coordinate wraparound teams for ten families with children/youth with complex CYMHSU needs. The prototype was evaluated at both an individual-level intervention (creating a collaborative team and support plan for a youth and family) and a systems-level intervention (developing relationships and patterns of collaboration among communities and agencies). Measurements indicate better outcomes for children, youth and their families like increased coordination and information sharing between all of the health, education, and social services involved in the life of the youth/family. These outcomes along with key lessons, challenges and system recommendations will be shared. Supported by Shared Care and the CYMHSU Collaborative, a partnership between Doctors of BC and the government of BC.
Wednesday, February 21 | 1415 – 1545
• RAPID FIRE
Nursing support and intervention for patients with chronic disease is of paramount importance. This is well established in a number of fields including diabetic, cardiac, and psychiatric care. Studies in other countries and jurisdictions have shown that nursing involvement improves delivery of care in patients with inflammatory diseases such as rheumatoid arthritis. However, incorporating nurses in a private practice model of rheumatology in BC has traditionally had many barriers.
Rheumatologists in BC funded a multidisciplinary care code, to be used in conjunction with nursing staff in patient consultation. This care code is designed for patients with inflammatory arthritis and chronic inflammatory conditions. It has allowed rheumatologists to hire nurses to assist in the management and education of patients with chronic inflammatory conditions.
Since the introduction of the code in BC, there has been a surge of nursing involvement in private practice rheumatology. Prior to 2011, there was just one nurse working in collaborative private practice rheumatology. As of 2017, 55 rheumatologists in BC have utilized the multidisciplinary nursing care code, which in turn has led to a fundamental change in our model of care.
The integration of nurses has resulted in the creation of the Western Canada Rheumatology Nursing Society to foster academic and educational exchange among nurses.
In addition, the interventions commonly supported by our private practice nurses have been studied in BC. These interventions have included vaccinations, injection teaching, and disease counselling. These services have the potential to improve comprehensive patient care, increase rheumatologist clinic efficiency, and reduce visits to other health care professionals.
Small towns naturally lend themselves to team-based care. In Summerland, BC, a family physician and group of school counselors teamed up to identify and co-manage the health of youth at risk.
Using the Practice Support Program Child and Youth Mental Health and Substance Use module, physicians, MOAs, school counselors and mental health clinicians from the community came together and learned common language and common tools. Relationships formed, and soon resulted in innovation and collaborative care.
With the local high school across the street from the doctor’s office it was relatively easy for the school counselors to walk with the students and introduce them to the physician. The youth’s trust, which is often hard-won by a high school counselor, was converted into a trust-by-association of the physician. This “street cred”, along with assessment results from the Counselor, gave the physician the starting point for a dialogue with the student. Shared communication between the physician and counselors, with consent of the student, resulted in an action plan reinforced by all.
This work was complemented by a rotating roster of physicians willing to take unattached youth into their practices.
The PSP module was complemented by the start of a CYMHSU Local Action Team, supported by the Shared Care Committee. The Local Action Team provided the longer-term forum for innovations such as physician-counselor team care to take root, be tested and modified into sustainable change.
Where youth may have before fallen through the cracks, the cracks are starting to be filled.
In looking at optimal Patient Medical Home team models, the Pacific Northwest Division of Family Practice Board of Directors reviewed a growing body of medical evidence that shows the progression of metabolic syndrome is the best predictor of pervasive, chronic conditions, including diabetes, cardiovascular disease and hypertension. Six PNW family physicians leads:
– Dr. Wouter Morkel, Smithers
– Dr. Onuora Odoh, Houston
– Dr. Matthew Menard, Masset, Haida Gwaii
– Dr. Jocelyn Black, Masset, Haida Gwaii
– Dr. Brenda Huff, Pacific Northwest
have formed CHANGE (Canadian Health Advanced by Nutrition and Graded Exercise) BC, to help to form a model, the first of it’s kind in BC that includes a Dietitian (RD) and Kinesiologist (KIN) to work closely with family physicians to provide customized, made in BC, evidence based lifestyle supports for patients. The physician leaders have partnered with Metabolic Syndrome Canada a nationally recognized, evidence based organization linked with top academic leads from 6 Canadian universities to bring the best science forward in the development of an optimal model to support GPs in addressing metabolic syndrome.
UBC has recently developed an innovative, cross faculty training site to help train inter-professional teams of GPs, KINs, and RDs, and has expressed an interest to work collaboratively in the development of CHANGE BC.
CHANGE BC is an emerging initiative that is too young to have results, however a March 2017 in CMAJ Open article that looked at CHANGE in 3 other provinces saw, after 12 months, 19 % of patients with complete reversal of Metabolic Syndrome, while 42% saw of a decrease in the number of Metabolic criteria, and the 10-year risk of heart attack was reduced for patients, on average, by 17%.
Presenters will discuss planed measures of Quality of Life perspectives from patients, cost effectiveness; the potential impact of CHANGE BC is significant in terms of both health systems savings, and improving quality of life and longevity for patients.
Wednesday, February 21 | 1415 – 1545
• RAPID FIRE
The Child and Youth Mental Health & Substance Use Collaborative was formed in 2013 with support by the Shared Care Committee, to improve timely access to integrated mental health and substance use services and supports for children, youth and families. Membership included 2600+ youth, families, and multi-sector service providers, including physicians.
In 2016 there were an estimated 1,065,104 children and youth aged 5-24 in BC (BC Stats, 2017); of which an estimated 181,067 to 213,020 will experience mild to moderate mental health issues (WHO, 2014). Access to child and adolescent psychiatrists in BC is limited, particularly in rural and remote areas. As a result, GPs, pediatricians and general psychiatrists are increasingly relied upon. In 2013/14, 91% of those 0-25 years old who accessed mental health services through health, did so through a physician. However, many physicians feel they lack sufficient training and experience to be able to assess, treat and manage the needs of this population.
In response, the Collaborative supported the development of Learning Links: Enhanced Learning Series in Child and Youth Mental Health. Learning Links is a free evidence-informed, 15-module interactive online learning tool that aims to improve access to medical specialists with expertise in child and adolescent psychiatry throughout BC. The modules track progress and physicians are eligible for self-directed learning credits.
Learning Links underwent pilot testing “by 28 pediatricians, general psychiatrists, and general practitioners from all regions of BC. The physicians who tested the modules reported gains in understanding children and youth with mental health disorders (85%), ability to identify (89%), ability to treat (82%), and confidence in treating (85%). A six month follow up, along with post-module surveys, corroborates these findings.
Use of the modules has expanded to nurses, social workers and clinicians in hospital and community settings.
Despite substantive efforts over the last decade to improve patient safety in Canada, patient harm remains a significant public health problem that must be resolved. The National Patient Safety Consortium, established by the Canadian Patient Safety Institute, has identified of critical importance the role that senior leadership and trustees must play in ensuring patient safety is an organizational priority.
A working group of national and provincial partners was convened to develop an educational plan for leadership and conduct an environmental scan. The report “Free from Harm” from the National Patient Safety Foundation (2015) was pivotal in this work. A key finding was the importance senior leadership and governance plays for being visible champions of patient safety and setting clear expectations for patient safety performance within the organization.
The working group has drafted a senior leadership bundle for patient safety/quality culture. It blends the key roles the CEO, senior leadership and governance play, with how the organizational culture engages and works to improve patient safety. The unique approach incorporates all elements for achieving a patient safety/quality culture. The bundle has a safety checklist of thirteen elements under three headings: enabling, enacting, and learning. Examples of elements include: CEO/senior leadership behaviours; patient and family engagement/co-production of care; situational awareness/resilience; and safety reporting/management/analysis.
In designing the bundle, methods included conducting an environmental scan of resources, leadership frameworks, and educational opportunities senior healthcare leaders are using to improve patient safety; and interviewing thought leaders for their impressions on the draft bundle. It is expected that healthcare organizations will use the bundle to assess their patient safety/quality culture and identify action plans for improvement.
Quality improvement (QI) initiatives are often designed to address areas of concern that are identified through the evaluation of patient morbidity data. While decreasing rates of patient morbidity will improve overall patient outcomes, this does not necessarily translate to an improved patient experience.
We designed a forum (QI Think Tank) with the goal of centering QI initiatives on Patient Experience.}
1. We engaged multidisciplinary teams of “QI champions” including frontline nurses and nurse practitioners, physicians, and allied health professionals. Selection of team members was assisted by unit managers. Several unit-based teams were assembled including orthopedics, general surgery, vascular surgery, gynecology, cardiac surgery, the operating room, pre-admission clinic, and post-anesthetic recovery room.
2. Former patients were invited to share their perioperative patient experience. Patients were asked to emphasize:
A) experiences which were positive which could be replicated
B) experiences which could be improved.
3. Teams participated in facilitated discussion to generate ideas for QI projects based on the presented patient experiences. Presenting patients were active participants in this discussion and were also asked to provide feedback on the QI-Think Tank process.
Results: Multiple patient-centered QI projects were proposed based on the shared patient experiences. An additional benefit was an enhanced level of engagement in the QI process based on the “connection” between patients and their frontline health care providers. There was also a synergistic benefit of having several multidisciplinary teams (from different surgical subspecialties) in the same room sharing ideas for projects.
Discussion: Patient-centered care is a popular catchphrase in health care circles, but how often do we go to the patient for input on how to improve care? We have designed a forum to center QI initiatives on actual patient experience.