- Fraser Health
Setting a Foundation for Engagement at RCH
Recognizing Physician Leadership: Dr. Nora Tseng
Dr. Nora Tseng is an active family physician, and one of more than 400 physicians who care for patients at Royal Columbian Hospital (RCH). A major tertiary care facility, RCH is one of the oldest and busiest hospitals in BC. It shares patient services and a combined medical staff with nearby Eagle Ridge Hospital (ERH) in Port Moody.
Dr. Tseng recently retired from her position as President of the RCH-ERH Medical Staff Association, and after leading an impressive two-year effort to establish the Facility Engagement initiative at those sites.
In the beginning, how was the idea of Facility Engagement received at your sites?
It could not have come along at a better time.
Royal Columbian always had a very strong identity, a unique culture. Old-timers, including myself, remember what it was like. It’s tertiary referral centre, but had a community hospital feel. The medical staff was pretty tight-knit. Physicians felt a sense of belonging and ownership. They felt they had more influence. They were doing a lot of extra things, basically, on a voluntary basis. But got paid in kind, right? Because there was a regard, a respect. So doctors were interested.
Then the health authority embarked on program management to create some standards in the region where there were disparities. It had some positive outcomes, but in the process of everything becoming regionally-based, individual sites got sidelined.
It was difficult for physicians, including those who were at a medical staff executive level or in a leadership position. There may have been some nominal consultation, but without really any influence. Medical staff kind of checked out from a hospital engagement perspective. “You come in, provide good patient care and then you go home.”
But it’s going back now to more emphasis on the site. And now they want to know our thoughts, co-address, manage, solve issues. So the pendulum is swinging back.
Why did you step into the busy role of establishing Facility Engagement at the sites?
I kind of fell into it [after a predecessor secured incorporation approval]. I was warned by an experienced physician that it was going to take a lot of time. So I was not unprepared, but still, it’s always surprising how much time it takes.
But it’s a job that needed to be done. Doctors always want to do a good job. And so, you know, it’s like, “Well, you need to do A.” Okay, fine. You get A done, then “Oh okay, actually, there’s also B."
Also for a lot of physicians, it’s a matter of giving back to the hospital.
What did you tackle first?
That first year was very busy with setting up the working group and meetings and asking for representatives. At the beginning, there was a representative from maybe half of the departments in the hospital, and now we have one from just about every department. We all have different strengths, different backgrounds. Knowledgeable fellow executive and an effective working group are invaluable.
We also have two sites with a combined medical staff. Eagle Ridge as a separate site felt disengaged and disconnected. So that is one of the things that we’ve focused on, and it’s improving.
These last two years our main focus was to establish a solid foundation and organized infrastructure. The next two years, the new executive will likely work more in collaboration with site and health authority leadership.
How did physicians respond?
We knew we had to engage the physicians first to have a more coherent and cohesive community or identity, so we needed to get our own house in order. And we needed to set priorities in-house, that were relevant to our medical staff.
So we’ve held four engagement events, two per year. We had a reasonable response to our first meeting. People wanted to know what Facility Engagement was about. I still remember the questions: “What does engagement mean to you? What are the obstacles and opportunities?”
When we went around to see how people felt, there were some strong common themes from which we could pull to develop our vision and mission. And from those discussions we were able to set priorities: 1) communication and collaboration among physicians; 2) communication and collaboration between physicians and site/health authority leadership; 3) information technology; and 4) patient care and system change. We later added a fifth priority: physician wellness. We have a concern around physician burnout. Even before we had FE funds, a group of physicians were working on that.
We made our first call for proposals in May of 2016 and received 28; then 22 in the second round, and five in the third round. We discussed and scored them. Some didn’t actually align, so there was a learning curve for both the working group and the proponents in terms of what kind of projects we would fund or not. By the last round we approved all proposals. In total we have approved 33 and seven have concluded.
It is actually an engagement exercise in itself when a group of physicians come together to evaluate and make decisions about proposals.
What improved for physicians in those first two years?
I think for medical staff, there’s an improvement. There was a lot of unhappiness at the first meetings. One of the signs of success is that when we went into our third meeting, the tone was different. It was like, “we’ve already moved past that.” So depending on whom you talk to, how physicians see the health authority has improved somewhat.
You know, several of the projects are for physicians within or between large departments where there is a need for better communication and collaboration. So they can get together and really establish a relationship. And the feedback has been good.
As well, doctors are using the doctors lounge more often for coffee, and run into colleagues there in a more informal, relaxed environment. We don't always know who some of the specialists are as the older physicians retire and the new physicians come on. So even if you put a name to a face, it does make a difference when you need to consult about a patient.
As you move on and leave this work in others’ hands, what is shifting and what is making a difference?
Before, people would say, “we have a problem, we're pulling our hair out, we have some ideas, but nobody wants to listen.” And there wouldn’t be a way to approach the medical staff to co-address an issue.
Now, people come up to us and say, “We’re having some issue with this and that and can we use Facility Engagement funds?” We have the opportunity to say, “Yes, you can submit a proposal.” Medical staff have a venue, get compensated, and feel more validated for your time and effort.
And I think there are improvements just in terms of the relationships. Within the health care system, we’re looking beyond the transactional aspects which is more about finances, budget and "do you meet your targets and what's your length of stay" - to the relational aspects.
We know good doctor-patient relationships correlate with better patient outcomes. We feel good relationships between doctors and the health authority will lead to better patient care.
Left to Right: Dr. Richard Merchant and Dr. Kathleen Ross with Dr. Nora Tseng.
Below: Royal Columbian and Eagle Ridge Hospital physicians exchange Facility Engagement project updates, November 2017.
Renewing physician-health authority teamwork in Fraser Health
The spirit of teamwork that once defined the culture of hospitals is on the road to renewal through BC’s Facility Engagement Initiative (FE).
“When I look back to the ‘80s, I worked in hospitals where physicians were leaders and had good relationships with staff and administration,” says Dr. Dayan Muthayan, Executive Medical Director for Fraser Health. “Then through the '90s, we saw a deterioration of relationships universally when health care became more about the bottom line. Physicians started feeling pushed away or withdrew from decision-making and leadership,” he says.
“So it is encouraging now to see a resurgence towards engaging staff and physicians, while putting the patient in the centre and trying to make the health system better.”
BC is not alone. Across Canada, pressures on health care budgets, rounds of organizational redesign and continual cycles of change have taken a toll on collaborative relationships among physicians and health authorities. Here in our province, the Facility Engagement Initiative aims to change that. Medical staff in 67 hospital sites across the province – including all 12 Hospitals in Fraser Health – are involved in activities to improve relationships, communication and collaboration; as well as their working environment and ultimately, patient care.
This is welcome news. Meaningful physician partnerships are critical to support the delivery of quality patient care, as well as our work to create an integrated, patient-centered health care system. Physician collaboration and leadership will ensure that our efforts and results are effective. By leading change together, we can also enjoy a more rewarding work environment.
Forging partnerships in Fraser Health
In late fall 2017, 15 Fraser Health physicians – including specialists and family doctors –and 18 Fraser Health executive leaders from 11 different sites met to discuss ways to improve communication, renew supportive relationships, and create a culture of open dialogue.
The gathering was one of many combined operational and medical leadership gatherings taking place or planned across the province, where meeting face-to-face is an opportunity to connect personally, and share perspectives about barriers preventing engagement – as well as next steps. A few examples of perspectives shared by participants follow:
ON THE OPPORTUNITY: We need to recognize opportunities for positive change when they occur and seize them. They don't always happen all that often, or in ways that can change what is happening in a fundamental way. We don’t know if this one will, but this one could.
ON PHYSICIAN LEADERSHIP: Facility Engagement allows physicians the time and ability to spring forth with some of their creative, intellectual, and innovative problem-solving abilities.
ON RELATIONSHIPS: Engagement is just another way of saying ‘relationships.’ The most important part of making effective change that benefits both and physicians and health authority and ultimately patients, is about having relationships you can trust.
ON BUILDING TRUST: It is an evolution. In the beginning, we needed to be reassured this was real, so activities were mainly doctor-focused. Then we moved to start projects to improve processes and make collaboration better. That has evolved over many months to inviting the executive director [of the hospital] to our meetings.
ON DECISION-MAKING: Consultation may not always mean being involved in co-designing decisions. Decisions are made in many different ways. We make assumptions and may think that our opinion did not matter. It is important to understand the method used.
We hit our stride when we moved from a checkbox approach early on, to now inviting the administration / executive to the working group for meaningful discussions.
ON BARRIERS TO ENGAGEMENT: Administrators come and go, and doctors stay. The constant shift is a huge challenge. Meaningful succession planning is needed both with the health authority and physicians when people leave, to retain the knowledge and institutional memory and get new people up to speed faster.
ON COMMUNICATING INFORMATION: It is important to communicate in a more timely way, and use multiple channels to distribute information. But whether by text or personal e-mails, it is just the transaction. It supports, but doesn't speak to the partnership we are trying to build. The relationship is the transformational part of this.
ON SUPPORTING GOOD ENGAGEMENT: Health authorities as well as physician groups need to model a culture of open discussion and transparency and develop solutions to engage physicians when that is not always possible [such as with union confidentiality matters]. We need to involve site administration early in meetings and hold joint partnership meetings with MSAs, health authorities and where needed, Divisions of Family Practice, to talk about collaborative goals.
Fraser Health Facility Engagement Activities
As of January 1, 2018, physician groups have formed in all 12 acute care sites where physicians and other medical staff members are now actively engaged in more than 100 Facility Engagement projects, including many collaborative activities that involve site administrators and staff.
It is early days, and laying a strong foundation of relationships and communication is an important first step to determine how Facility Engagement evolves.
“We're proud of how far we have come in just a year’s time, from setting up legal structures to making significant impacts in the lives of physicians, health authority representatives and patients,” says Dr. Muthayan. “It will be exciting to see where we could be over the next two years.”
- Interior Health
Patient Simulation Expands at Kootenay Boundary
Photo credit: UBC Faculty of Medicine, Okanagan Campus
Facility Engagement is supporting medical staff from several departments at the Kootenay Boundary Regional Hospital in Trail to participate in the development of a simulation curriculum for different staff groups. One physician will work on ER based simulations, another will provide simulations for OR teams, and another will focus on providing "just in time," clinically-based simulations for critical care teams. After developing the curriculum, the physician lead for each area will also learn how to run the simulator, and provide educational sessions. The work will support local physicians and improve patient care.
-------------------A perfect storm for patient simulation is generating new education and training opportunities at Kootenay Boundary Regional Hospital (KBRH) in Trail. As the acute care facility for Interior Health (IH) in the West Kootenay and Boundary region, the hospital supports a rural population of approximately 75,000 people. KBRH also serves as a primary learning environment for students with the Southern Medical Program (SMP) and resident physicians with UBC’s Kootenay Boundary family practice site.Dr. Scot Mountain, Director of the Intensive Care Unit, is one of the local physicians working closely with IH to develop a dedicated patient simulation centre for health professionals and learners.
Lillooet physicians work with partners to increase local mental health care access
Like many rural and remote communities, Lillooet has struggled to provide appropriate local care for children and youth with mental health issues, particularly when they visit the Emergency Department and are then sent to the regional centre like Kamloops for psychiatric treatment.
Generally these are short-term solutions. Young patients return to the community with no follow-up available and often end up back at Emergency.
A solution was initiated by Dr. Humber and the Lillooet Hospital MSA physician group. The physicians worked together with local and regional Interior Health representatives, along with schools, First Nations councilors and other community members, to arrange for two Child and Youth Psychiatrists to provide outreach clinics to Lillooet and surrounding area.
With travel being a challenge even in the best weather, a blended model of face-to-face and virtual telemedicine was established, to enable physicians and patients to hold virtual follow-up appointments to reduce time between visits.
The value of the combined approach became evident when, during summer wildfires, road closures and nearby evaluations resulted in cancellations of the in-person outreach clinic. Patients were looking forward to their appointments, and thanks to the virtual telemedicine setup – and the collaborative process that made it possible – every patient was able to continue being seen by the psychiatrist.
Vernon physicians work to curb unnecessary repeated patient tests
At Vernon Jubilee Hospital, Dr. Jason Doyle brought forward concerns about redundant laboratory testing. Unnecessary, repeated rounds of tests for admitted hospital patients appeared to be occurring, and could potentially be preventable by modifying protocols.
The Vernon Jubilee Hospital Physician Society (VJHPS) arranged for a small representative group of physicians to examine laboratory utilization and develop recurrent laboratory testing guidelines for inpatients (such as guidelines for daily CBC orders).
They agreed on simple rules to govern, streamline and limit ordering of tests while patients are in hospital, and worked with the health authority to make changes to ordering practices at the unit clerk level. Through their Facility Engagement work, physicians had the opportunity to collaborate with the site and staff to implement the new guidelines.
As a result of the changes, we hope that patients will experience less anxiety and discomfort and will avoid unnecessary tests and that cost savings will be realized.
- Island Health
Victoria physicians collaborate to improve endoscopy services
As part of the Facility Engagement Initiative at the Victoria General Hospital, a group of gastroenterologists identified a priority to schedule endoscopic (ERCP) procedures in a more efficient and effective way. In the past, there would have been significant roadblocks to this kind of change as it would involve adjusting staffing practices, hospital room allocation and more.
The project’s physician lead, Dr. Denis Petrunia, reported that the funding facilitated getting all of the physicians impacted by previous ERCP booking model to attend initial discussion and planning meetings. As a result of this, members of the administration became aware of the complex issues and were then motivated to support the changes recommended. The groups organized a series of meetings to discuss how to reorganize the ERCP scheduling.
As a result, changes in scheduling practices for weekday procedures have now been successfully implemented, and the group is in the process of evaluating the outcomes and cost savings over the next few months.
Bringing real meaning to the word ‘team’ in Victoria
At the Royal Jubilee/ Victoria General Hospitals, the Facility Engagement work brought together physicians and staff from the hospital and health authority who might not otherwise have been in the same room together. The physician lead, Dr. Bruce Wong, an emergency room doctor, was looking to access data to generate and test an algorithm to predict individual patients’ wait times when they present in the ER. A meeting was set up between the ER doctor and staff from Decision Support at Island Health.
Given an opportunity to meet, they discussed not only the data about ER wait times, but also the overall work done by Decision Support to inform the provision of health services. Dr. Wong also happened to be responsible for drawing up the schedule for all ER physicians, and commented that a heat map generated by Decision Support - showing times of day when patients most likely to leave the ER without being seen by a physician - had directly informed his scheduling practices.
The staff from Decision Support were delighted to hear that their reports had made an impact on health decisions; one data analyst said “We just crunch the numbers and write the reports, but it’s so exciting to hear from people who read them!” It was a mutually satisfying meeting for all present. The ER doctor left the meeting knowing more about the kind of data he could access and what the Decision Support staff could do to help, and the staff at Decision Support left with validation for what they’ve been doing and a greater understanding of the ER physicians’ needs.
- Northern Health
Improving Quality of Care Across the North
The University Hospital of Northern British Columbia has been experiencing a year-by-year increase in acuity level of patients cared for by internal medicine services.
As a proactive measure to build and sustain capacity, and to ensure that medically-complex patients continue to receive high quality inpatient and outpatient care, members of the Department of Internal Medicine, Northern Health Authority and other physicians and stakeholders have embarked a three-point plan. It includes:
- Enhanced inpatient general internal medicine services, delivered by a multi-disciplinary team, to support patient admissions seven days a week.
- Coordinated outpatient care that includes clinics where there is little delay between when a patient is referred and seen for a consultation.
- Expanded weekday general internal medicine consultation services to support patients across the region using a broad range of distance services, such as video consults.
The plan, which will take about two years to implement, aims to improve the quality of care in both inpatient and outpatient settings. It will double the capacity of inpatient care, to sustain the availability of those services when needed. At the same time, it will establish a robust system of outpatient care to promote diagnoses of patients, and ensure they can get the care they need outside of the hospital, which in turn can reduce emergency room visits and hospitalizations.
The three components of the model provide a comprehensive solution to the unique challenges faced by the University Hospital of Northern British Columbia. A fulsome evaluation plan has been developed collaboratively by the physicians and health authority to measure progress and impact.
It is expected that the fruitful partnership of physicians working closely with health authority administrators to find solutions and develop a plan will be one of the key success factors of this initiative.
Internal Medicine Department physicians, University Hospital of Northern British Columbia. From left to right: Dr. Firas Mansour, Dr. John Smith and Dr. Anurag Singh. Absent: Drs. Amin Lakhani and Sharla Olson, Anne Chisholm (Health Services Administrator), Julie Dhaliwal (Manager Medicine)
- Vancouver Coastal Health
Vancouver physicians come together to share unique lives, build community
The Vancouver Physician Staff Association (VPSA) has introduced a "Unique Lives in Medicine Luncheon" where physicians can connect and hear about their colleagues' passions outside of clinical practice. It is part of the VPSA's Facility Engagement work to create a more connected, collaborative and caring physician community.
Dr. Rod Tukker, a hospitalist at VGH, was the featured guest at a recent luncheon. He highlighted the Street2Peak Project, the expedition he joined to lead 15 youth to the top of Mount Kilimanjaro. From the streets of Vancouver’s Downtown Eastside (DTES) to the top of Africa’s highest peak, Dr. Tukker shared his experience with vulnerable youth and the lessons they taught him about strength and resiliency. Read story here >
Technology Innovation Engagement Forum brings physicians together
Creating a Community of Innovation
Dr. Doug Courtemanche demonstrates an innovative tool for trainees, teachers and programs
More than 150 physicians, healthcare leaders and industry partners attended the first-ever Technology Innovation Engagement Forum held January 25 at VGH. The event provided an opportunity for physician innovators to share their insight and experience and make connections to support the development of innovative technology solutions for health care.
“This event is about bringing people together to start the conversation about the role of technology in healthcare,” said Dr. Kendall Ho, who co-chairs eFIT (engagement For Innovative Technologies) with Drs. Eric Cadesky and David Wilton. This is just the beginning.”
Innovative ideas in action
Dr. Corinne Hohl, VGH emergency physician highlighted a software application for reducing repeat adverse drug events, Dr. Jan Venter, family physician, shared a “check-engine light” concept to monitor brain vital signs such as in concussions, and Dr. Igor Brodkin, VA Anesthesia compared the OR activity whiteboard to airline industry technology, which inspired the creation of an OR real-time Activity Display Board. These were among the many ideas shared throughout the evening.
The event, sponsored by the VPSA Facility Engagement Initiative, VGH & UBC Hospital Foundation and supported by Vancouver Coastal Health, was also livestreamed via webcast. Tweets were flying as presentations sparked ideas and generated interest. There are already requests to hold another forum again soon.
Physicians “connect, collaborate and care” at Vancouver General Hospital
Whether they work at a hospital, centre or in the community, VCH-Vancouver physicians share a need for stronger relationships across sites, disciplines and communities.
And that’s not all. They also say they want to participate more in decision-making that impacts their workplace and patients. VCH leaders support these priorities, and the Vancouver Physician Staff Association (VPSA) Facility Engagement Initiative has organized a number of events to bring physicians and leaders together.
A catalyst for collaboration
The VPSA Facility Engagement Initiative was established in the fall of 2016 to strengthen relationships, improve communication and collaboration between physicians, and create a more unified physician community.
“We apply a ‘Connect, Collaborate, Care’ approach to bring physicians together, and we’re now extending this same approach to start engaging with VCH leaders,” says Dr. Lyne Filiatrault, co-chair of the VPSA Facility Engagement Initiative.
So far, the initiative has funded 10 physician-led projects and multiple engagement events. Starting in January 2018, the initiative is sponsoring a Breakfast with Leaders series.
Physicians and leaders highlight priorities for creating a more connected and collaborative work environment.
Connecting over croissants
Establishing connections and understanding roles were on the menu at a breakfast meeting hosted by the VPSA Facility Engagement Initiative on December 4 at VGH. Mary Ackenhusen, VCH CEO and president, and Glen Copping, VCH CFO and vice president of systems development and performance, joined the more than 50 physicians, medical directors, operations directors and others in attendance.
Building on the success of its December event, the VPSA then launched its 2018 Breakfast with Leaders series on January 11. Mary Ackenhusen participated again in the event, that focused on physicians’ reasons for choosing to work at VCH and their priorities for improving their work experience.
Meaningful engagement a priority for all
Physicians and VCH leaders are committed to keeping the communications channels open and working together to address priorities in the year ahead. The VPSA Breakfast with Leaders series, along with project activities and other engagement opportunities, are examples of this commitment to collaboration in action.
Dr. Marshall Dahl shared priorities identified during group discussion with colleagues.
Contributed. Read full article here >
Looking after physician health at Vancouver General Hospital
Most physicians would agree there are not enough hours in the day to fit everything in. Patients are the priority, which means “luxuries” like exercising and socializing often get pushed aside. As a result, many physicians are isolated from their colleagues and neglectful of their own fitness and health needs. A new program, funded through the Vancouver Physician Staff Association (VPSA) Facility Engagement Initiative brings physicians together – for fitness and for conversation.
Physician-only spin classes are offered in the Centre for Cardiovascular Excellence at UBC Hospital. Classes are free and available every Tuesday at 6:30 am and every Thursday at 6:00 pm.
A personalized approach:
Physicians create a profile, which they will log into at the beginning of each class when they select a stationary bike. Progress is tracked and physicians are provided with objective measures of their fitness after each class so they can compare results and monitor improvement over time. Physicians also have the opportunity to participate in a monitored telemetry session providing continuous ECG.
A healthy breakfast is served after each morning class, providing time to connect before getting on with the day. VPSA funding supports the trainers, cardiovascular technicians and pays for breakfast.
“So many physicians are feeling burnt out and disconnected, this class gets the endorphins flowing and helps strengthen relationships among physicians and across disciplines,” explained Dr. Saul Isserow, Physician Project Lead for this initiative. “When physicians look after themselves they are in a better position to look after their patients.”
Collaborative, coordinated effort improves ED flow & capacity at Lion's Gate
Dr. Kristian Hecht, a Emergency Department (ED) physician at Lions Gate Hospital (LGH), thought there was a better way to leverage the floorplan and manpower available to the Emergency Department (ED). She had watched as ED patient volumes increased steadily each year over the past seven years – often the patient volume exceeded the ED capacity. Out of necessity, the waiting room sometimes became the treatment/assessment space.
The Lions Gate Hospital Physician Society as part of the Facility Engagement Initiative supported Dr. Hecht in pursuing this work.
Dr. Hecht saw that the First Aid area with its 19 patient care spaces could be transformed to manage and assess ambulatory patients and the RAZ area changed into the First Aid space. In addition, the ED wanted to adopt a patient assessment/treatment process developed at a Calgary ED.
This two-pronged approach was proposed and involved collaboration and coordination with ED stakeholders (MD, RN, EHS, RT, DI, portering, stocking, lab and ECG), LGH acute care administration and LGH project management office.
Triaging to new zones allowed both spaces to be used adequately and sharing the workspace between MDs and RNs far improved communication. The patient assessment/treatment process better organized the waiting room and enhanced patient safety. Recliner-style treatment chairs provided more effective use of space, while maintaining patient comfort and privacy. Touchdown assessment rooms prevented patients from blocking care spaces and allowed ample space for assessments/consultations. As well, re-directing patient flow reduced redundant tasks.
The result is improved patient flow through the ED, reduced patient wait times, improved communication between MDs and RNs, decrease in non-physician tasks, improved patient safety and satisfaction, and improved organization and scalability for future demands.
Record physician turnout for disaster preparedness at VGH
A record physician turnout for a Disaster Preparedness Day for Vancouver General Hospital was made possible through the Vancouver Physician Staff Association (VPSA) Facility Engagement Initiative. Eleven physicians were able to participate in the event, along with two Vancouver General Hospital (VGH) emergency physicians and a trauma surgeon who helped to coordinate the day.
In total, more than 60 participants took part in the all-day event which was designed to test VGH's capacity to respond in a disaster situation, and was led by Susan Harris-Salt, Nurse Educator, ED and a team of VGH emergency nurses.
"The day was a success from a physician engagement perspective and as a disaster preparedness event," said Dr. Chris Lee, one of the two emergency physician leaders. "Having this many physicians participate is a great improvement from our last event."
Staff rely on established protocols and processes to guide them during a disaster situation. These were put to the test during the Education Day as the group launched into a table-top exercise with role playing providing valuable insight into what works, what needs to improve and how people are likely to respond.
In addition to testing protocols and processes, participants rotated through skills development stations including needle chest decompression, tourniquet application and radio readiness. Representatives from the Canadian Armed Forces and Canadian Blood Services also participated.
The event identified opportunities for improvement, including the involvement of more key stakeholders, such as ICU and radiology. Organizers were pleased with the results and the lessons learned. The success of the day was due in part to the many physicians who took part. An ongoing process, the next exercise will lead up to a full-scale, city-wide exercise to be held in spring 2018.