- Fraser Health
Surrey Memorial Hospital to start emergency physician residency program
Burnaby Hospital Engagement Efforts Pay Off
Education Forum: Community Physicians Meet Specialist Services
Project Lead: Dr. Chris Bozek
Burnaby community physicians had little information about the existing speciality services and resources that Burnaby Hospital can provide to their patients. Furthermore, some physicians expressed lack of awareness about how to successfully refer their patients to the speciality clinics such as the orthopedics or neurology clinics at Burnaby Hospital.
This initiative aims to increase the knowledge and awareness of the hospital's specialty services, and establish effective communication between all physicians to improve patients’ experience in receiving timely and appropriate care. This helps to provide the right treatment to the right patient at the right time - every time.
Project Team: An initial steering committee was formed with the Burnaby Hospital project champion and Executive Director, and the Division of Family Practice, to discuss potential topics of discussion and best way(s) to present information. Three meetings were held, and a number of different topics were generated.
Project Outcomes: 3 education forum events have been held with over 30 participants attending:
May 3, 2018 – Ortho 101 - Review of the central intake for Orthopedics
- Overview of hip arthroscopy and minimally invasive hip replacement
-10 myths around Orthopedics
- Roundtable discussion
October 18, 2018 – Neurology - Migranes/Headaches
- Multiple Sclerosis
- Seizures & Epilepsy
- Neuromuscular Disorders
- Roundtable discussion - Improving Access to Neurology Consults in Burnaby
April 10, 2019 – Chronic Pain Management - Procedures for pain management
- Medical management of chronic pain
- Pain management programs
- Roundtable discussion – Future initiatives on pain management wants and needs
Participant feedback was collected for each of the education forums. The feedback was positive with physicians requesting additional events to be held. Burnaby family physicians feel that this is a great forum to interact with sSpecialists and allow for feedback on hospital programs. It also provides an excellent forum for Burnaby Hospital specialists to promote the specialised services available to patients in the community.
Reducing Inpatient Echocardiograms
Project Champion: Dr. Sarah Ostler
An echocardiogram (Echo) provides information about a patient’s cardiac condition. This test is available to both inpatients and outpatients at Burnaby Hospital. Many inpatients remain admitted in the hospital waiting for their Echo test, unnecessarily extending their inpatient length of stay. Currently, 43% of the echocardiograms performed at Burnaby Hospital are ordered for inpatients. In 2017, approximately 51% of these inpatients remained admitted an average of 5 days longer than their expected length of stay (ELOS); where some of them could have alternatively received their test as outpatients.
Having patients wait for tests as an inpatient slows down the flow of patients’ discharge, reduces the hospital’s bed capacity, puts pressure on staffing, and unnecessarily challenges the hospital’s resources and their optimal operational allocation.
To solve the issue, a team of four physicians set a goal to reduce number of patients receiving inpatient echocardiograms. They trialed a new requisition form to test its effectiveness. Feedback was sought from the physicians and booking clerks to identify opportunities to improve on both the “document” and the “booking" processes. The trial was then repeated with a larger group of physicians in specific departments, then spread throughout the entire hospital.
- Site-specific echocardiogram booking requisition form created
- Education to support improved patient identification for outpatient booking
- Adoption of an electronic booking process:
- Standardize the booking process
- Standardize the information provided to appropriately book an Echo
- Reduce potential for errors in the system by spreading it across Fraser Health
The Project Team: Teamwork was critically important in carrying out a project of this scope and successfully implementing change. Having a multi-disciplinary team provided the right amount and level of expertise that was needed to move forward in decision-making and tackle challenges. The hospital administration was supportive and heavily involved in the project as it involved operational process changes, and the following resources/departments were included:
- Medical imaging
- Clinical form services
- Clinical policy office
- BUH Admin
- Unit Clerks
Project Outcomes: The project was a major success as By June 15, 2019, the number of patients receiving inpatient echocardiograms at Burnaby Hospital decreased by 15%. A project poster presented at the Physician Quality Improvement conference won 1st place.
Enhanced Recovery After Surgery (ERAS)
Project Champions: Dr. Gavin Gracias & Dr. Katherine Hsu
The delay until full recovery after major abdominal surgery/rectal-pelvic surgery and radical cystectomy has been greatly improved by the introduction of a series of evidence-based treatments covering the entire perioperative period and formulated into a standardized protocol. Compared with traditional management, Enhanced Recovery After Surgery (ERAS) represents a fundamental shift in peri-operative care. The ERAS-care pathways reduce surgical stress, maintain postoperative physiological function, and enhance mobilisation after surgery. This has resulted in reduced rates of morbidity, faster recovery and shorter length of stay in hospital (LOSH) in case series from dedicated centres and in randomized trials.
Changes Made (ongoing)
1. PDSA checklist on charts to collect data
2. Patient education post op – providing booklets/questionnaire
3. Implementation of ERAS protocols i.e carb drink and warming blanket
The Project Team: The ERAS project is a Fraser Health initiative. Facility Engagement funding enabled physician champions to develop a strategy to implement ERAS at Burnaby Hospital, to liaise with local nursing and administration to facilitate implementation of ERAS, and to oversee implementation. Monthly meetings have been held with physicians, hospital administration, and nurses.
Project Outcomes: The project is ongoing and has been successful in implementation of ERAS protocols. As this is a Fraser Health initiative, having physician involvement has been key in moving the project forward. The next steps include collecting data to determine its impact.
Crucial Conversations: Skills to Deal with Daily Challenges
Project Champion: Dr. Paul Johar
The Crucial Conversations course helps people master the skills needed to candidly and respectfully handle high-stakes conversations, achieve better results and enhance relationships. At Burnaby Hospital, 35 physicians and 5 administrative staff members attended this 2-day course. Both worked together to improve skills needed to engage others when addressing challenging issues. They learned to recognize when a conversation becomes crucial and received tools they could use to deal with daily challenges.
This course was originally offered in 2017 with 40 Physicians attending, and due to its popularity was brought back in 2019. As a result of the 2017 course, a crucial conversations club was started at Burnaby Hospital. This club enables physicians to identify challenges facing physician leaders and utilize the skills learned in the course to deal with them.
Project Outcomes: 40 learners participated in the course with 35 registering in the learning management system and 21 providing feedback regarding their experience. The course was well received by learners with 95% of respondents saying they were satisfaction rate with the course, that is was a worthwhile investment of their time and that they would recommend to a colleague.
Participants enjoyed the practical learnings in the course and enjoyed learning from knowledgeable and experienced faculty. They are ready to go back and apply the skills in the workplace by preparing for the difficult conversations and focussing on an outcome that is mutually acceptable to all parties. Learners expressed interest in future training regarding engaging others, managing people effectively and leading change.
Physicians Advocating for Wellness: Thinking Bigger
Last November, Fraser Health’s regional Medical Staff Wellness Committee welcomed 45 physician health champions from its 12 hospitals and 10 divisions, as well as health authority leadership, to brainstorm how Fraser Health could support and promote physician health. As their ideas unfolded, the Committee realized that they were sowing the seeds for a regional Physician Health Program.
Dr. Connie Ruffo, physician health champion of Peace Arch Hospital’s Physician Wellness program was co-lead for the November event. She has been involved in physician health efforts for more than a decade. She notes that “physician health” includes not only physical, mental and social well-being but the element of professional fulfillment which gives happiness and meaning in work.
She sees three influences on our well-being as doctors:
Dr. Ruffo refers to a landmark Mayo Clinic study which revealed that organizational-driven efforts which address workplace drivers of burnout (e.g. work flow, efficiency, technology) and provide opportunity for self-care, reduce burnout and promote engagement, can have an even greater effect than physician-driven wellness events.
- How we care for ourselves. “Basic health practices –what we eat, how much we exercise, sleep, connect with family and friends. This, combined with resilience skills such as boundary setting, mindfulness, and energy management eases the distress of burnout; but alone won’t prevent it. This element is very much under our control.”
- How we care for our colleagues. “This involves connecting and reaching out to support one another. Humans are wired to connect. We listen to our patient’s stories everyday. It is also important for doctors to share their stories. Sharing and connecting means feeling safe enough to be vulnerable. Doctors understand doctors. This gets to culture, and changing how we communicate and interact with each other.”
- How we engage in changing the system. “Once physicians become better connected, then it is easier to build healthy teams. Whether in the OR, the ER, hospitalists or other specialities, or divisions of family practice, we are all part of the system. Physicians have key skills and insights, and a professional responsibility to be leaders, advocates, educators and innovators. Together we really can influence system change. We can educate administrators and executive decision-makers, initiate and lead patient quality improvements and projects, and provide input on system proposals or decisions that will impact how we do our work to care for patients, and our well-being. Facility Engagement funds are an amazing opportunity to do this. We can choose where to direct our energy to make system changes to areas that burn us out.”
"There are many organizational interventions that require small investments, yet have a very large impact. Involvement by physician leaders, and administrator attention to these factors were key to its success," she says. Examples include supporting teamwork, training compassionate leaders and enhancing EMR efficiency.
“This is a very exciting time for those of us that have been involved in physician health over the years. There is an explosive amount of research being done around the world. There are new tools for measuring well being in physicians. And, province-wide there is a phenomenal grass-roots movement occurring among doctors, who are declaring their need for vigorous community- based wellness programs, which are supported and acknowledged both regionally and provincially.”
FRASER HEALTH SHARES ITS SUMMARY OF FINDINGS
Fraser Health’s Medical Staff Wellness Committee wish to share the findings of their experiential workshop with other MSAs, divisions and health authorities,with the view that taking the priority of physician well-bring to an organizational/ system level will help to raise awareness and stimulate action around this urgent issue across the province. Some of the themes and directions they want to start exploring are here.
Acknowledgements: The event developed for the FH Medical Staff Wellness Committee would not have been possible without the work of Dr. Elizabeth Froese and Dr. Laura Kelly. Also, the support of Dr. Dayan Muthayan, Physician Partnerships, Fraser Health and Facility Engagement Director Cindy Myles were instrumental in its realization.
- Physician Health at the individual and system level: Canadian Medical Association policy > (Go to abstract and download PDF)
- Mayo Clinic: Organizational Strategies to tackle physician burnout > (Go to abstract and download PDF)
Hospital-wide engagement creates a quality improvement culture
Quality improvement champion Dr. John Hwang has teamed up with Royal Columbian Hospital administrators and frontline staff to build a culture of continuous improvement across the hospital.
The seed was planted in 2015 when Dr. Hwang and a team of frontline staff organized a “QI Day” for surgical services with the support of RCH administration. At the time, little was known about quality improvement activities around the hospital, so this was an opportunity both to teach participants about the importance of frontline engagement and to celebrate the accomplishments of unit-based QI teams.
Based on feedback from the inaugural QI day, the organizing team developed a series of frontline engagement workshops. The aim was simple: to teach those working on the frontline that continuous quality improvement is part of every provider’s job, and that making small changes within their scope of practice can collectively lead to big improvements in patient care. The following year, quality measures that had been stagnant for a decade showed notable changes in just about every area, ranging from surgical site and urinary tract infections to pneumonia.
Buoyed by those successes, the QI team (newly dubbed the "RCH QI League") expanded the effort right across the hospital in 2018 with a series of regular workshops leading into an annual QI Day in the spring. Physicians, front line staff and administration from all clinical services and departments contribute ideas, and learn how move them into action. With the support of Facility Engagement, physicians are able to take time to attend the sessions and provide ongoing leadership and mentoring. Participation has grown year after year.
Results are measured, and annual improvements are acknowledged, celebrated and spread across departments. “The first year we saw remarkable results. But the success was not a result of just one thing,” says Dr. Hwang. “It was because we focused on culture. So I see this ongoing effort not just as a QI Day, but a culture day – the recognition that everyone on the team has a responsibility to look within our personal scope and improve care as we can.”
Photo credit: Wendy D Photography/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
Widespread engagement jumpstarts overcapacity solutions
- “Trying to solve the problem of too many patients in your hospital absolutely has to involve everyone finding solutions. This is a great jumping off point to use some resources we have we didn't have before to get us someplace we couldn't have gone otherwise.” - Dr Charles Casselman
Advancing a big vision for change
Most hospitals in BC experience over-capacity and access and flow challenges to varying degrees, and have held multiple meetings over the years to look at solutions. But despite best intentions, many of those ideas stall after everyone gets back to their busy jobs.
Dr Charles Casselman, Chief of Staff for East Kootenay Regional Hospital, set out the change that.
As big vision thinker who works behind the scenes, Dr Casselman knew that the first step to success was to get the right people at the table. Physicians are rarely able to attend meetings during clinical hours, yet their voice is critical to the conversation to ensure that plans involving patients are workable.
So he leveraged the Facility Engagement opportunity to bring together the brightest minds for a pivotal planning workshop in May 2019. While Dr Casselman rallied the physicians, Erica Phillips, the Interior Health Acute Health Service Administrator for the East Kootenays, worked to have health authority administrators to attend events after hours.
Bringing stakeholders together: an abundance of ideas
The May forum – attended by 78 people including 27 physicians, 25 Interior Health representatives and other stakeholders – not only generated an abundance of rich ideas and perspectives, it set out foundation for an ongoing collaborative effort. A third party consultant firm, Reichert and Associates, took the feedback and along with data research and patient and stakeholder interviews to set out some longer term recommendations.
On June 24, the same group came together again to hear recommendations from Reichert. Participants were energized to meet again and consider the opportunities ahead. Even local elected officials attended, excited to see what might change for people living in the community. Now the group will plan out next steps to action the recommendations.
Support for change: not just off the side of the desk
A key missing link – not available in the past – was within reach: a dedicated support team with MSA project manager Jill Bain and administrative help was waiting to jump into action to break the changes down into manageable steps, and to keep them moving along among the partners. And while there is still much work ahead, there is plenty momentum around the shared vision that is propelling the plan forward. Stay tuned.
MSAs who wish toget a copy of the Reichert overcapacity recommendations can contact: email@example.com
WATCH VIDEOS: Collaboration and change at EKRH
Courage and community come together to improve surgical quality and safety
Dr Michel Hjelkrem, an orthopedic surgeon at Kootenay Boundary Regional Hospital took what some might consider drastic steps to reduce surgical site infections – he stopped doing joint replacements. Then his four partners joined him. This was in late 2017 and for the next two and half months, they embarked on a mission to improve surgical standards. And while it wasn’t always an easy road, it turned out to be one of the best decisions they made to lower infection rates well below the national average.
The hospital administration was initially reluctant to delay patient procedures. But with support from SSC’s Facility Engagement Initiative – the physicians were able to initiate meetings and discussions to get everyone working towards the same goal, which included taking a pause and making some changes. At the time, infection rates were about 2.8%, compared to the national average of 1% to 2%.
“Morbidity and mortality associated with infection is a big concern,” said Dr Hjelrem. “If you get an infected joint replacement you’re looking at a minimum of three more surgeries, extended time in the hospital, extended intravenous use, complications, toxicity. It’s difficult to get rid of.”
A hospital-wide effort
The entire hospital - from specialists and managers, to nurses and students, to cleaners and engineers – was engaged to join the effort. “It takes a community to prevent infection,” he said. “We needed everybody to be involved.”
The first step was to have the hospital upgrade its ventilation system. In the four ORs, air ducts were cleaned, a HEPA filtration system installed and room temperature, humidity and pressure became better controlled.
A new leader was secured for Medical Device Reprocessing (MDR), responsible for instrument cleaning. Surgical staff reviewed their processes and tightened up their actions. An expert reviewed orthopedic procedures over several months and provided education and awareness.
Dr Hjelkrem and his team also worked with GPs to ensure patients achieve the best health possible prior to surgery by developing criteria that included optimizing weight and reducing risk factors related to smoking and dental health. They also looked at how post-op patients were cared for - ensuring they recovered in a different room from other infectious patients - and introduced software to prevent deep vein thrombosis.
Going the extra mile
In January 2018, the changes were in place and the surgical program restarted. For a year after that Dr. Hjelkrem continued to advocate for one more addition which is known to substantially decrease infection rates. The process involves ‘decolonization’ or sterilizing the nose with a laser and special ointment, as well as using special wipes customized for pre-op patients. At about $50 per patient, it took some convincing to have the cost of the procedure covered. But given the average cost of an infected joint replacement in Canada is about $30,000 to $50,000. “By preventing one infection, we pay for our program for two years,” Dr Hjelkrem noted.
Trail became the second hospital in Canada to introduce the procedure, and Dr Hjelkrem notes that other hospitals noticed and expressed interested in adopting it as well.
The results speak for themselves – infection rates dropped well below the national average, to 0.4% after just one year – and less than six months after the procedure to sterilize pre-op patients was implemented – the infection rate dropped again to 0.2%. In addition, a lot of actions taken weren’t confined strictly to orthopedics – so the overall infection rate for the hospital has also dropped by 50%.
As results revealed themselves, others jumped in to join the effort. “We started getting suggestions from even more people coming up to me and and saying, ‘Hey, what else can we do?’” Cleaners suggested that iPhones be kept out of the OR. Engineers offered to change filters during the smoky summer months. Nurses wanted CPAP equipment reviewed. Even patients got involved, with suggestions like “I’ve had this band on my arm for a week, shouldn’t it be cleaned?”
“There is no doubt that most important component to our success was the engagement of everyone in the hospital – no one was left out,” said Dr. Hjelkrem. “It’s been a really, really positive experience. There have been some heartaches and bumps along the way, but the end result is that we’re achieving a large part of what we set out to do.”
Happy, safe patients
Best of all: improved quality and safety. “We have had such great response from the patients. It’s been unbelievable. There’s been a lot of really good stories that have come up because we’ve been so diligent about optimizing our patients. We’ve become a hospital that people now want to come to to have their surgery,” he said.
“A local retired physician recently told me that he’d want his wife to have her knee replaced at KBRH because we have such a reputable infection prevention program.”
MSAs: Your Facility Engagement Liaison can connect you with this project team if you wish to get more information.
Recognizing Facility Engagement excellence in Achievement, Partnership, Innovation, and Teamwork
Celebrated at FEI Interior Regional Showcase and Networking Event
Last year, Interior Health Facility Engagement Initiative (FEI) facilities participated in the Site Review and Reporting Process to share feedback about the work being done and to develop plans for the year ahead. The calibre of work and projects was outstanding, with many of the facilities’ projects and initiatives truly exemplifying excellence.
MSAs, health authority partners, and project staff were brought together to recognize efforts that have inspired, sparked change, and brought the Facility Engagement Initiative to life in the Interior Region. Four of these facilities were further recognized by Facility Engagement for Excellence in Achievement, Partnership, Innovation, and Teamwork.
CERTIFICATE OF EXCELLENCE IN ACHIEVEMENT – recognizing a project/initiative with robust evaluation showing measurable and significant results, aligning with the goals of the FEI’s Memorandum of Understanding.
The Kootenay Boundary Physician Association (KBPA) and Regional Hospital (KBRH) was recognized for their support of progressive work that, through the power of engagement and perseverance, improved patient outcomes in their facility.
The post-operative infection rate at KBRH was 2.8% - well above the national average. Orthopedic surgeon Dr. Mike Hjelkrem, along with four of his surgical colleagues, set out to improve it. Through engagement with stakeholders at all levels and departments, from cleaners to engineers to health service administrators, the team identified a multitude of improvements that reduced infection rates down to 0.2%.
CERTIFICATE OF EXCELLENCE IN PARTNERSHIP – recognizing strong successful partnership between medical staff and Interior Health – involving early and often collaboration.
Shuswap Lake General Hospital (SLGH) was recognized for their leadership in collaboration and partnership.
This group has gone above and beyond to collaborate with local, regional and corporate Interior Health stakeholders. The SLGH FE working group has developed an ‘open door policy’ for their meetings which encourages a diverse group of Interior Health members to attend. They have developed a strong partnership with local and regional Interior Health staff by including the most appropriate IH representatives for solutions, challenges and ideas. The IH Senior Medical Director and Health Service Administrator have partnered with the SLGH physicians to collectively work on facility challenges, using the 2018 FEI Interior Regional Meeting 10 Recommendations as a foundation for change.
INNOVATION AWARD - recognizing a new/creative approach to a complex problem accomplishing positive change.
The partners at the Creston Valley Hospital were recognized for their work to create a new maternity clinic in the region.
Eighteen months ago at Creston Valley Hospital, three physicians providing maternity services – Dr. Barry Oberleitner, Dr. Crystal Campbell, and Dr. Karen Persad - approached Interior Health with a proposal to develop a clinic within the hospital and health centre that would integrate maternity services and include public health nurses. As a result, the multi-disciplinary Maple Maternity Clinic opened at Creston Valley Hospital this year. Physicians, Interior Health administrators including Acute Health Service Administrator Erica Phillips, Site Director Deb Austin and Site Manager Carolyn Hawton, public health nurses, staff and community partners, worked together to transition maternity care from two clinics in Creston to a centralized clinic at the hospital.
TEAMWORK AWARD - recognizing a project/initiative that has featured large involvement of the working group, physician leads, and larger MSA involvement, demonstrating excellence in teamwork by physician engagement.
Royal Inland Hospital (RIH) in Kamloops was recognized for outstanding efforts in teamwork, engaging significant and diverse members of their medical staff team.
With a physician membership of over 300, the Royal Inland Hospital Physician Association has worked tirelessly to engage their medical staff so that they can prioritize patient care needs. 60% of MSA members - representing every department at RIH – are either leading or participating in over 44 FEI activities. Physicians stepping into leadership roles are supported and united with other medical staff and have the ability to bring things to the forefront with administrative leaders. In 2018, RIHPA participated in the formation of the Thompson Medical Alliance to align physician initiatives in the Thompson area that includes: Facility Engagement, Divisions of Family Practice, Practice Support Program, Physician Quality Improvement, IH Quality Improvement, and IH Research.
The changing landscape of engagement in Interior Health
Facility Engagement Regional Showcase and Networking Event, Kelowna - October 22, 23 2019
What a difference two years has made.
Last month, Interior Health Medical Staff Association (MSA) physicians, project leads and health authority partners joined together in Kelowna to share Facility Engagement experiences, knowledge and strategies, and to celebrate the progress that has been made since they first gathered two years ago.
At that time, the tone was decidedly different. Physicians expressed frustration about their relationship with their health authority, and according to the 2017 Doctors of BC Health Authority Engagement survey, only 28% of them felt that Interior Health (IH) was a good place to practice medicine. IH leadership listened, and responded with a genuine commitment to make things better.
Two years later, the initial sentiment is turning around. Now, 51% of physician respondents to the 2019 Doctors of BC Health Authority Engagement survey say that IH is a good place to practice medicine.
So how did things change? A combination of factors. In addition to committed regional leadership that supports a culture change, local Medical Staff Associations have been working enormously hard to improve communication, trust and collaboration amongst physicians and health authority counterparts in their own hospitals and health regions.
Dr. Harsh Hundal, Executive Medical Director for Interior Health Physician Engagement & Resource Planning, says a key ingredient is driving change.
“What this speaks to is relationships – seeing each other as people. Relationships underlie everything. We’re on a journey together. You don't engage facilities, you engage people, and in order to engage people you need to see the world through the complexity of what they deal with.
Everybody wants to do a great job. But we recognize that we have been working silos. Let’s reach out to partners, get to know them, ask them how they are doing.”
On that growing foundation of relationships, MSAs from across Interior Health have been able to collaborate with their health authority counterparts in ways that were not possible in the past, and to successfully advance dozens of improvements at their sites.
For the 27 physicians, 21 project staff, and 18 IH administrators who attended the October 23rd event, the opportunity to share experiences and learnings was buoyed by optimism and energy. While there is still a lot of work to do, all signs are pointing towards a healthy, growing culture of engagement across Interior Health.
REFLECTIONS FROM EVENT PARTICIPANTS
“Changing culture is a slow process. You have to make efforts to change it. And it is totally worth it.”
“I didn't think I would be interested in these leadership roles, but as I got involved I am quite interested, and it really gives me an idea of how things work. It is not useful to just sit in your office to complain about things - it is worthwhile to come out here and change things.”
“When in leadership, don’t be afraid to show enthusiasm and ask questions. Step forward and ask questions: how does this work?”
“Face to face and networking – being present in the room together – whether having conversations together at coffee, dinner, or social activities are equally as important as standing in front of a room with a mic.”
“We are hearing over and over again you have to have that relationship piece built before you can make any real change or expect any work to stick. Solidifying those relationships is the foundational work that needs happen before any real change can be expected.”
"Engaged physicians who are excited about where they work and making it a better place are the best recruits for this work."
"The most exciting part of this shared learning experience was the honest, open, two way dialogue around major issues facing the physicians delivering care locally with the Health Authority leaders. The need for transparency and conjoint identification of problem areas, barriers and limitations were major themes. The most inspiring outcome was a clear agreement to continue collaborative discussions and shared decision making moving forward." (Dr. Kathleen Ross, President, Doctors of BC)
United voices improve physician engagement across Interior Health
There has been a major shift in physician engagement across Interior Health in the last year.
With physician-administrator dyad partnerships, quality improvement projects, and facility engagement initiatives, physicians have strengthened relationships with administration, are more connected to resources and training to improve the work environment, and have established activities and strategies to improve areas of need at the site level.
“I am incredibly humbled by the work of our medical staff across IH. They are taking the time to have meaningful and constructive conversations about the things that matter and then making positive changes. It is their passion and drive that is having the greatest impact to the work culture, the patient experience, and the quality of care.”
- Dr. Harsh Hundal, Executive Medical Director, Physician Engagement and Resource Planning
Physicians ‘unstick’ a project to introduce local treatment options
The Facility Engagement Initiative has identified and implemented many health improvement projects in a number of hospitals across BC, but sometimes its value is in helping ‘unstick’ a project – like one that languished for about two years. The project - to develop a uterine fibroid embolization (UFE) program within the Royal Inland Hospital (RIH) in Kamloops.
A similar program has run for about 20 years in the Lower Mainland. Women in Kamloops with severe symptoms caused by fibroid tumors whose other treatment options were unsuccessful or more invasive faced the decision of having a hysterectomy or travelling to Vancouver for a specialized minimally-invasive procedure of fibroid embolization.
Fibroid embolization treatment
The fibroid embolization treatment involves puncturing an artery in the body and having an Interventional Radiologist guide a catheter into the uterine arteries and injecting tiny particles that float into the uterus to block off the blood supply to the fibroid tumor(s) – eventually shrinking or killing them. The procedure is done in an angiographic suite in the Radiology Department and only requires an overnight stay once completed.
Championed in the region by Dr Michael Burns an Interventional Radiologist – a proposal was put together three years ago in conjunction with Dr Brooke Cairns of Kelowna General Hospital who was also interested in establishing a UFE program.
The proposal was first submitted to the Interior Health’s (IH) Health Technology Assessment Committee, who approved it in 2016. It was then that Dr. Paula Lott, a Gynecologist and committee member with the RIH Physician Association suggested to Dr Burns that Facility Engagement (FE) could take this on as a project. However, by 2018 final approval and funding from IH was still not moving along.
Collaboration gets things moving
It was with Dr Lott’s help that the project got moving again connecting Dr Burns with the right Interior Health administrative people. At the same time, the Ministry of Health were looking for ways to free up OR time. Establishing the UFE program was one way to help because it reduced the need for hysterectomies to treat this issue.
Soon Dr Burns found himself connecting and partnering with IH Peri-Operative Management Committee, local administrators, managers and gynecologists. “In particular IH administrator Sue Gardner-Clark was very helpful once we got the greenlight – she helped get the local process off the ground.”
Since it is a new procedure, FE also funded the time Dr Burns needed to engage in these meeting, write protocols, determine steps to educate IH staff in the radiology department, technicians, nurses, and daycare surgery staff; as well as write new post-procedure orders and protocols, patient advice sheets and so on. Dr Burns said, “Staff were very interested and open to it, but they wanted to be sure the procedure was safe and that they were appropriately trained to deal with any complications.”
Taking an extra step for safety and quality
As a new program, Dr Burns also followed a new technique by puncturing the left radial (wrist) artery rather than the femoral artery at the groin. This is safer for the patients and doesn’t require them to stay lying flat during post-operative recovery. The program began in April 2019. It is estimated that between 20 to 30 patients a year could eventually benefit from this new and less invasive technique.
Proactively supporting physician wellness at Royal Inland Hospital
Physician wellness and burnout are often common issues discussed among the physicians involved in Facility Engagement. At the Royal Inland Hospital (RIH) in Kamloops, an annual RIH physician engagement survey first addressed the need for a physician wellness initiative. Contact with Doctors of BC’s Physician Health Program eventually led to the recommendation that RIH establish a Physician Wellness Committee.
Established in late 2018, the committee is supported by the Royal Inland Hospital Physician Association and led by Dr Megin Fong. Dr Fong believes in fostering physician wellness because “you can’t really help your patients, if you are not taking care of yourself first.”
The committee’s activities included conducting a needs assessment survey, which found physicians wanted particular attention paid to team-building, support and recognition.
As a result, the committee developed three distinct programs: R.I. Health, Recognition @RIH and Asclepius Peer Group. While R.I. Health encourages team-building through a variety of educational/informational workshops - for example billings and audits - and Recognition @RIH highlights the achievements of physicians in the hospital and community – the Asclepius Peer Group pilot program is all about team-building and support.
Asclepius Peer Group - A safe, anonymous environment
The peer group pilot program held weekly 1-1/2 hour meetings over an eight-week period with a maximum of 10 physicians. During the meetings, physicians discussed their challenges, critical incidents, impact of their work and so on. The meetings were facilitated by a professional and anonymity was maintained so physicians had a level of safety and trust that what they said remained ‘in the room’ and confidential.
The first cohort of physicians have recently finished the program and feedback included a positive response to the impact of these meetings, which promoted deeper connections among the participants.
“Based on the experience I had attending the Asclepius Peer Group; incorporating balance into my own practice of wellness would include fewer late nights in office and more relaxing activities.”
A second eight-week cohort begins in October and based on feedback from the first physician group – the focus will be to provide physician participants with tangible skills and exercises to maintain wellness in both their professional and personal environment.
Eventually, these groups will help address and support physician wellness by identifying strategies and actions that will shift the culture and alleviate physician burnout well into the future.
Kelowna General Hospital ER orientation & mentorship initiative
Last year, the KGH Emergency Department was busy hiring new locums and permanent Emergency Medicine Physicians.
Dr. Brandy Bursey, ERP, recognized that there was no formal orientation or mentorship program in place to prepare the new recruits for working in the hospital’s busy ED. Wanting new recruits to be prepared and welcomed into this new environment, Dr. Bursey, together with her colleagues Drs. Karla Tujik and Jennifer Williams, received funding from the Facility Engagement initiative and began work on developing an orientation manual for new staff.
The covers a wide array of “need-to-know” information which has been well received by new Department members.
In addition, the project team assigned a mentor to each new Emergency Department physician to welcome them and have a go-to person to connect with should they have questions. This greate idea helped to improve the work environment for new Emergency Medicine Physicians, supporting them to be successful in their roles.
Other medical departments have been invited to create an orientation manual if they wish.
(Originally published in the KGH Physician Society Newsletter)
Facility Engagement helps Creston centralize maternity care with a new maternity clinic
Three physicians have led the way to a collaborative effort between physicians, interior health administrators, nurses and staff to centralize maternitycare in the Creston area.
As a result, a new clinic was established within the hospital to integrate maternity services and bring multidisciplinary teams together to provide pre, peri and post-delivery maternity care.
Funding for the collaborative effort was provided by Facility Engagement, a partnership of the government and Doctors of BC.
Read the full news release here.
Coffee, Colleagues and Gratitude Cards
~~When staff arrived at the Kootenay Lake Hospital on the morning of Monday July 30, they smelled coffee and saw their colleagues gathered around a café that didn’t exist before. The environment had changed to a warmer and more welcoming one. Everyone was encouraged to join, and were served a cup of coffee and a muffin before writing on ‘gratitude cards’ about what and who they appreciated in the hospital.
Acknowledging the fact that the staff at the Kootenay Lake Hospital had not come together as a group of colleagues over the last two decades, Dr. Gregory Hand, the Facility Engagement Working Group Chair, thought it was time. A few months prior when elected, he started meeting with individual physicians during lunch. After hearing input from those meetings he realized that real engagement wouldn’t be possible without creating a positive work environment and opportunities to bring together staff and physicians in casual environments.
Dr. Hand can be seen in the above picture using an espresso machine to make coffee. After reviewing their strategic engagement plan, the MSA realized that they did not have a place to meet, like a lounge or a café, and came up with a brilliant idea of having a casual pop-up café. They named it “Appreciation Café” and invited everyone at the hospital - from nurses to physicians, clerks, patients and cleaners - to join.
As Dr. Hand recalled, “When we thought about who we were trying to engage, we initially thought of medical staff peers. But then we also realized that if we want to bring changes to the hospital environment, we had better consider engaging other people like the administrators, the staff, as well as the public.”
Two-hundred appreciation cards were collected, attached to banners and displayed at the main entrance of the hospital. Here are some of the messages:
- “Management cares about staffing needs, and patient concerns, dilemmas and stressors.”
- “Supportive, hard working environment that also has time for a smile and a laugh.”
- “I am grateful for being part of such a healthy, happy, joyful team. Great personalities here at KLH.”
As a result of this initiative, “people were really happy,” Dr. Hand said. “All the staff seemed to feel connected. There was a sense of camaraderie. It was pretty inclusive and a good starting block to build on.”
The MSA held two more pop-up cafes with the support of Facility Engagement. The Interior Health administrator, Thalia Vesterback is now looking for a permanent space and contractor for a coffee shop at the hospital.
Facility Engagement is one of nine SSC initiatives that helps build relationships and assists in finding effective solutions for medical facilities across BC.
Big challenges sometimes find easy fixes
[Picture-from left to right: Dr Allison Howatt, General Practitioner at SLGH, Peter Du Toit, SLGH Hospital Administrator]
Working in a small, rural hospital like Shuswap Lake General Hospital (SLGH) can present some unusual challenges. Sometimes these challenges have an easy fix – particularly when the right people get in the room to talk about them. Facility Engagement (FE) is all about getting the right people together to collaborate and improve both their relationships and patient care.
Dr Allison Howatt, a GP at the SLGH with enhanced OB/GYN skills saw an opportunity to fix a growing issue around care for babies born with premature lungs requiring respiratory support. The hospital only had one way to deliver this care - through a neo-puff system, which required a health care provider to physically hold the equipment in place to maintain pressure – often for many hours until the infant is transferred to a higher level of care facility. The process could be both physically draining and time consuming for healthcare providers with so many other responsibilities.
When an infant transport team member asked Dr. Howatt, “Why don’t you guys have a proper C-PAP machine?” she took up the challenge, and put it on the table as part of capital planning considerations for Interior Health. A C-PAP system provides automatic seal and support needed for pre-mature newborns’ respiratory support.
The request moved slowly until Facility Engagement became active at the hospital, and newly-hired Project Manager Yuliya Zinova got to work to formalize meetings between the MSA and Interior Health. “This was when things started moving,” says Dr. Howatt. “Our interior Health partner understood the need, and the administrative support was provided by Facility Engagement.” FE Project Manager Yuliya Zinova arranged meetings with both physicians and the health authority administration, inquired about equipment to be funded by Interior Health, and arranged for funding physicians’ time spent training through Facility Engagement once the equipment was purchased.
“My precious commodity is time, and because of Yuliya’s help, we were able to take a good idea and turn it into reality,” noted Dr Howatt.
Peter Du Toit, Interior Health’s hospital administrator who sits on the Facility Engagement committee representing Interior Health said, “the discussions about the need for a CPAP system helped me better grasp the issue. FE helped speed-up the hospital’s purchase of the CPAP ventilator by at least three to six months.”
Facility Engagement is one of nine SSC initiatives that helps build relationships and assists in finding effective solutions for medical facilities across BC.
David Matear, Executive Director of IH West on Facility Engagement Initiative
For the Executive Director of IH West, David Matear, Facility Engagement and collaboration with the Chief of Staff, and the President and Vice President of the Royal Inland Hospital Physician Association (RIHPA) is helping solve a lot of issues facing the region.
David points out that one of the biggest challenges for the region has been minimal physician engagement at various levels, including involvement in decision making and understanding of the health authority’s strategies. “We need to realize that neither physicians nor administrators are successful as independent entities and they need to come together as collaborators to health system planning and delivery to ensure patients and families in our communities receive the highest quality of care.”
To further enhance this collaboration, Facility Engagement also provides learning opportunities where physicians and health authorities are able to work on joint projects to improve their facilities, something unprecedented in the history of BC health administration.
The joint leadership model (called Dyad) promoted by Facility Engagement is something that David really appreciates. “This model helps a great deal not only with creating partnerships and collaborative efforts, but also with enhancing the quality of the existing relationships by bringing out the best in people and utilizing those skills”. As an example, he referred to the process of “bringing together the physician leaders working on their projects and the IT leadership of the Interior Health to create a project inventory and provide strategic direction to support virtual care in IH West.”
David supports the work of Facility Engagement without hesitation, noting that “bringing physicians and administrative leaders to the same room sets the scene for a common understanding and is the beginning of a relationship.”
As of June 2018, there are 45 projects that are being supported by FE in IH West. Together with its partners, IH West went through an extensive process of strategic planning in January to set goals for the region, and involving physicians in those discussions. “This is huge. We are jointly discussing the goals for the next year. We’re basically on the same page, collectively, to facilitate health care delivery with a joint sense of responsibility.”
David concludes, “Even though we have a long way to go towards working together naturally and effortlessly, the realization that we no longer need to have separate conversations is a great lead into the future. While we move forward, it is important to keep reminding ourselves that the more collaborative our decision making, the more mature we become as a community of health care providers.”
Saving the Elk Valley Hospital Operating Room
Little did they know that the retirement of their only general surgeon at Elk Valley Hospital (EVH) in Fernie would bring about a significant opportunity for collaboration with both the physicians in the neighboring community and their Interior Health partner.
Having no luck with recruiting a new specialist surgeon for the hospital, despite a strong partnership with local governments to assist the recruitment efforts, physicians and staff started thinking about what could be done to save the OR. After all, this retirement could mean that surgical services in Elk Valley Hospital would have to close down and over 15,000 residents in Fernie, Elkford, Sparwood, Elko, and Jaffray would have to travel as much as 170 km to the nearest hospital in Cranbrook both for consultations and surgeries. Road conditions during the winter could make it even more challenging for patients to receive surgical care, especially for pregnant mothers requiring a C-section. Increased pressure on hospital staff and resources in Cranbrook from the additional elective day surgeries could also lead to longer wait times in that community.
In order to identify a solution that would save and sustain the OR in Fernie and not destabilize OR services in Cranbrook, physicians came together through funding from Facility Engagement to create a Surgical Sustainability Committee. The committee included representation from the physicians and Interior Health Authority (IHA) including the Chief of Staff, Health Services Administrator, Health Services Director, Site Manager, Medical Administrative Assistant, and Patient Care Coordinator (head nurse).
The solution conceived was both creative and sustainable, and involved the engagement of all parties. First, a Family Practitioner with Enhanced Surgical Skills (FPESS) was recruited to regain a slate of elective day surgeries in Fernie. However, as the FPESS was not starting for 12 months, the committee reached out to the Surgical Unit at East Kootenay Regional Hospital in Cranbrook, the neighboring city, to discuss an opportunity for them to perform surgeries at Elk Valley Hospital - with a goal of meeting patient needs closer to home while creating an opportunity to add sustainability to both surgical programs.
Through one-on-one personal phone calls made by committee members, specialist physicians in Cranbrook were able to discuss the opportunity and express their interest formally. EVH Physicians attended a Surgical Leadership meeting in Cranbrook to present the opportunity at their rural facility, and build their relationship with the Surgical Specialists.
Cranbrook surgeons were provided with all relevant information for working at Elk Valley Hospital, including the OR schedule of open days, an offer to have Fernie nurses travel to Cranbrook for a day to observe the surgeons’ working styles to build mutual comfort levels, and coverage of travel costs for surgeons through Northern and Isolation Assistance Outreach Program (NITAOP).
In addition, an examination room was secured at Elk Valley Hospital for patient consults and equipped with furniture, donated local artwork, a fridge, and a nespresso machine to serve as a comfortable ‘home away from home’ for visiting surgeons as a model consultation space and a comfortable private space to take breaks between surgeries.
On the first day of work, Elk Valley Hospital staff and physicians came together for lunch sponsored by Facility Engagement to welcome and meet the visiting surgeons. Jacqueline Arling, the Facility Engagement Project Manager for Elk Valley Hospital, believes that the key to this solution was relationship building. “A big factor for the surgical sustainability success is that physicians have built trust and relationship with both the Cranbrook physicians and Interior Health.”
The residents of the Elk Valley now have four visiting general surgeons conducting consults and surgery at the Elk Valley Hospital, in addition to the current GPs and soon-to- start FPESS physician. The surgeons are proud of being able to help a neighboring community in need of specialist care. Taking collaboration to yet another level, these surgeons can also help mentor the local FPESS to expand their capabilities to perform surgeries in Fernie.
Reflecting on the success in Fernie, Karyn Morash, Health Services Director said, “With the advent of Divisions of Family Practice and Facility Engagement the way physicians were coming to the table was changing, it facilitated our ability to work more closely together.” while noting that “to the health authority’s credit, we have worked with determination to honor our part of the commitment to engagement with MSAs.”
Given the historical communication challenges that existed between health authorities and facility-based physicians, Elk Valley Hospital is a perfect case example of solution finding made possible through collaborative efforts leading in turn to improved patient care--the ultimate goal of the physicians, health authority and the Facility Engagement Initiative.
Facility Engagement in Interior Health: Dr. John Falconer
When I think about where we started only a few years ago, I’m very excited ... Physician engagement among the groups continues to be excellent and growing. To me, one of the positive impacts has been the interdivisional and interdepartmental opportunities to regularly collaborate, such as pediatrics meeting with emergency or radiology meeting with surgery; these cross-collaborations are new. Read More >
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
Vancouver Island physicians "Where I work, live and care"
Dr. Bruce Campana, Dr. Omar Ahmad and the South Island Medical Staff Association have launched "We Are Island Health" - an inside look at what matters to medical professionals from Victoria to Tofino and Port Hardy, and what makes their work special.
Heart Health Team aims to improve AED data sharing
When a person experiences cardiac arrest, paramedics and first responders may use an Automated External Defibrillator to help “re-set” the heart rhythm. Not all cardiac arrests receive a shock, but all AEDs collect important heart rhythm and rate data that can help the Heart Health team determine what caused the heart to stop and guide treatment decisions.
However, this data is not always easy to get. Dr. Daisy Dulay, Randall Town, Laura Shaw and Rosie Holmes set out to improve how the AED data is shared ....Read full story here > (originally published on Island Health's Medical Staff website.)
Medical staff collaborate on business plan to replace Cowichan District Hospital
Planning a hospital is a massive, complex undertaking involving collaboration by a multitude of stakeholders. Physicians have an important role to play to contribute clinical expertise to the planning as it occurs and before decisions are made, to ensure future services meet the needs of patients.
It’s why the Cowichan District Medical Society (CDMS) took the opportunity to engage physicians soon after the concept plan for a new hospital was approved by the province.
“The CDMS approached Island Health with an offer to support physician involvement in the development of the business plan,” notes Dr. David Robertson, Executive Medical Director for the region. “This offer was welcomed and has helped ensure robust input from the physicians during this early phase of the project.”
With Facility Engagement funding and engagement opportunities made possible through CDMS, physician/medical staff members are working together with administrators and nursing staff to help Island Health create the business plan for the new hospital. The plan will also include input from patients, local First Nation communities and community stakeholders.
Physicians/medical staff have opportunities to:
- be involved in discussions and attend meetings to provide input into the plan
- visit and learn from other hospitals to contribute ideas and learning
- research best practices in care delivery to contribute to design and functionality
The business plan is the 2nd of 5 phases for CDH redevelopment. Island Health will submit it to government for approval in fall of 2019.
COMOX / CAMPBELL RIVER: Facility Engagement Changed Everything
~~When the Campbell River and Comox Valley Hospitals (one-hospital, two campuses) opened last October, the transition from the old St. Josephs’ Hospital was welcome, but rocky. The design of the new spaces were not as workable as expected, and patient flow and congestion challenges in the ER escalated within the first few weeks. Around the same time, patient visits increased significantly. “Within the first few weeks, the entire back half of the emergency room was filled up with admitted patients,” says Dr Albert Houlgrave, Emergency Room Physician and lead on this Quality Improvement project.
He explains that physicians and frontline staff were feeling stressed about the congestion and patient safety, but did not feel their concerns were being heard by health authority administrators who were not in the hospital every day. So they met on their own time to brainstorm solutions - a process that created good ideas, but also created some friction with the health authority counterparts, who were not involved in the discussions.
That’s when Facility Engagement came along, and the Physician Engagement Society of Courtney & Comox Initiative (PESCCI) was formed. The groups began to talk. Facility Engagement created a platform for dialogue between physicians and administrators to look at their common goals. “Facility Engagement funding relieved some of that pressure to be regularly volunteering our time and energy when so many of us were already extremely busy”, he says “And it created a culture where we could meet to discuss solutions to the problem and subsequently meet with administration to put those ideas into action.”
Once meetings started, improvements happened quickly: a dedicated trauma bay, a hot stroke protocol, simulation training, redeployed nursing support for waiting patients, improved hospital signage, a new paging system and space redesign for new beds. “It was great to have administration on our side to help free up space and make new space for beds.”
Physicians, nurses and unit clerks also began to review patient cases to find further improvements to flow and efficiency, and with administration, were able to put their ideas into action.
“While we have been working hard within the ER to improve the frontline work, we have also been reaching out to other departments.” said Dr Jennifer Laurence, the co-lead physician on this project, adding, “To date we have had the Laboratory Department, Maternal/Child, ICU, and the Medical/Surgical Unit invited to our quality meetings to review issues of concern regarding patient care and ongoing relationship building between our departments.”
Today, the situation has turned around completely. Communication and teamwork between physicians and administrators has grown, and the culture has evolved. “We have more time to give, and have been supported by PESSCI under the umbrella of quality improvement, flow and efficiency,” says, Dr. Houlgrave. “From there, it has blossomed into a multitude of mini-projects and ideas.”
Dustin Spratt , Manager Emergency & Critical Care, ICU for Campbell River and Comox Valley Hospitals notes that administrators and physicians are enjoying a good working relationship, close communication and regular meetings, and are now looking at collaborating across the two sites. “The importance of Facility Engagement is critical in providing good quality patient care,” he says. “We have front line clinical and administrative operational levels of responsibilities. And to make it function well, we need to have good communication and relationships. Through collaboration we’ve been very successful with managing the change, and have been able to put a lot of quality improvement into play. Everyone is now collaborating around quality goals and successfully managing important changes.”
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
Optimizing patient safety in multi-team obstetrical emergencies
Physicians at the University Hospital of Northern British Columbia in Prince George have been working with each other, as well as administrators and frontline staff to improve team work and communication between the Departments of Obstetrics, Pediatrics and Emergency.
The goal: to work more efficiently with each other during emergency situations and provide better patient care, especially for high-risk obstetrical cases.
Communication errors can sometimes be a cause of perinatal death or injury during an obstetrical trauma. The departments involved wanted to reduce this risk by improving communication, fostering mutual respect and clarifying the designated roles of various member of the team.
Dr. Maria Odulio lead the way to bring together Obstetrics, Neonatal Intensive Care Unit, Emergency, Nursing and Respiratory Departments for a workshop. In total, 67 participants took part, representing:
- Respiratory technicians
- Unit Clerks
- Perinatal Council
- Risk Management
More than two-thirds of those who attended learned something new, such as helpful or critical information related to various codes (Code Pink , Code Blue, Code Neonate, etc.) , the role of Respiratory, the importance of a good patient handover and the debriefing policy. They also learned the importance of clear respectful communication and role clarity. In the future more multidisciplinary simulations can be used to prepare for emergency situations.
‘I just wanted to say a big thanks for all the work you (Dr. Odulio) put into today. I thought it was a great success - a welcome start to important conversations and improved teamwork’ - ED Physician Participant
‘I just wanted to thank everyone again for a very successful workshop…the evaluations are overwhelmingly positive with 9-10/10 for helpfulness’ - Northern Health Clinical Nurse Educator
Lens replacement protocol helps the whole community
Like many communities in BC, Terrace faces a shortage of family doctors and the local health care community is continually looking for ways to maximize capacity in primary care.
At Mills Memorial Hospital, physicians identified a way support these efforts, by streamlining the process for cataract surgeries which in turn, would reduce the number of visits patients need to make to their family doctor’s office before surgery.
Lens replacement surgery for cataracts is performed at the hospital about 97 days per year, with an average of 13 procedures performed each day. This adds up to roughly 1261 procedures per year performed in the hospital. And because patients need to be assessed by their family doctor before their surgery, the primary care appointments also add up, placing further pressure on wait times and access for other patients to a community GP.
Physicians at Mills Memorial Hospital identified that many of the patients’ pre-operative primary care visits for uncomplicated lens replacement procedure are unnecessary, or redundant. So the ophthalmology group and the surgical committee - led by Dr. Abe Torchinsky and Dr. Andrea Geller - along with the corporate executive lead for surgery and allied health staff, set out to streamline a pre-operative pathway.
They established a process that eliminates the need for a history and physical exam to be performed by the community GP. Instead, the Canadian Ophthalmological Society guideline which requires assessment of the patient by a health care provider can be met in the ophthalmologists’ office without the need to routinely involve GPs.
Encouraging and far-reaching results
The result? A limited trail involving a subset of patients attached to a family doctor in Terrace was successful in reducing the number of primary care visits needed for a pre-operative history and physical exam. A review of 4 slates of cataract surgery in May 2019 showed a total of 31 patients (65% of the total) were not sent to their GP prior to surgery.
With full adaptation of the changes in guidelines, it is estimated that more than 1200 primary health care appointments can be created in the region annually - appointments which would otherwise not be available.
The impact of this collaborative effort and its positive changes is far reaching. Freeing up appointment time in family practices will increase timely appointments and access for other patients, improve patient experiences, and increase productivity and cost efficiency in the system as a whole.
While this pilot project enjoyed the success of meeting its stated objectives, more quality improvement work is necessary to ensure sustainable and positive change. Areas of further research include an analysis of lens replacement slates over time, and an exploration of the patient experience. Additionally, ongoing dialogue and collaboration with Northern Health Administration and the Director of Care is necessary so that amendments to policies and procedures occur as a result of the project.
Physicians and Northern Health collaborate to introduce secure texting
For most of us, texting has become second nature as a fast and easy way to communicate. But in healthcare, technology has taken time to catch up.
“Physicians know that you can’t talk about sensitive confidential information through text messages,” said Dr Brian Hillhouse, and family doctor and emergency room physician at the University Hospital of Northern BC (UHNBC).
The advantages of texting however, he explained are many. Information is right in front of the doctor when needed. A text is less intrusive and more responsive than a phone call or voice mail, making it easier and faster to share information needed for patient care, especially when a timely response is needed. “It’s very efficient and handy for practice.”
Recognizing that texting could be an invaluable communication tool for doctors to use in their clinical work, Dr Hillhouse took the opportunity with Facility Engagement to initiate a collaborative project with Northern Health to create a secure texting app for physicians.
Getting on the same page
After doctors were polled to confirm that texting could improve their job functions, Dr Hillhouse, with six colleagues as fellow tech testers, and Northern Health’s IT department, embarked on a collaborative effort to see what could be done. The physician group discovered that Northern Health’s IT team had already been looking into technology options for secure texting. At the same time, the IT team did not realize that physicians were also interested.
“Things were so much better when we brought the IT developers and end users [doctors] together into the same room to look at the needs from our respective viewpoints,” he noted. “Physicians were able to explain their practical day-to-day needs, while IT was able to advise about functionality and appropriate use of the tool.”
Ron Klausing, a Project Manager for Northern Health IT, along with Dr. Bill Clifford, Northern Health’s Chief Medical Information Officer (CMIO), were a huge source of support. “As a former family doctor in town, Dr. Clifford understood where we were coming from,” he said.
The group first tested a application product ('app') already used by the hospital’s maternity and ICU departments and realized that it wasn’t a good fit. They settled on a product called MicroBloggingMD, which provided robust security features to meet BC’s privacy act. “We had a demo and a prototype period to try out the app,” said Hillhouse. “It worked better than we ever would have thought and had different functionalities that we didn’t even know we needed.”
Improving communication for patient care
As a start, doctors working in their community practices receive an alert when one of their patients is admitted to hospital. Then, as a big step forward, physicians working at the hospital can use the app to connect to the patient records system, so they can search for a patient’s name and be linked to the chart.
Physicians can also exchange information and photos securely with each other for consults and handovers, and communicate with nurses and residents. The app will soon notify doctors of critical lab results.
Dr Hillhouse said that radiology is one of the highest users. “We can alert them to prepare for an urgent CT, and get a text back about whether the scan is positive or negative.”
“So, it’s all in your pocket.” He noted that with pagers and voice mail, it isn’t always clear if communication has been received. “This way, we get acknowledgement when a message is read. So we know it has been dealt with and can worry about other things.”
The app also provides physicians with a way to get in touch with each other, bypassing the hospital switchboard. It includes a directory of all Northern Health departments and physicians, as well as an on-call schedule with clickable link, so physicians can connect with each other immediately.
More than 50% of physicians have begun using the technology so far, with further adoption expected. “It is not our main and only way of communicating, but it is very convenient”, said Hillhouse. “It is an exciting opportunity to be able to use texting in medical practice in a secure and safe way, and one way of improving the efficiency of medical practice.”
He noted that the physician-health authority collaboration was a critical success factor. “Having end users working together with the design team will ultimately lead to higher uptake and satisfaction with the tool,” he said.
HOW IT WORKS
Information is transmitted through the app but is never stored within the app or in the company’s software, or on the phone itself, or in a cloud (such as Apple’s icloud).
All information flows through and is stored on Northern Health servers.
Security software is installed on phone itself and within the application, with a 6 digit passcode, facial recognition and encryption features.
Northern Health IT has ability to control the phone if lost or stolen including to lock or erase it.
All details of conversations are retained by Northern Health for legal purposes.
Application costs are based on inpatient beds, not the number of users, so everyone from physicians to nurses to students can use it without increasing costs.
Costs: Northern Health covered the app and project management, while physician time, coordination and engagement support staff costs were covered by Facility Engagement.
MSAs who wish to explore secure texting can get in contact with your Facility Engagement Liaison (FEL) for knowledge-sharing opportunities and to find out if your health authority or other sites have any plans in the works.
Facility Engagement improves teamwork & patient care in the North
Dr. John Smith, Past President of Medical Staff at the University Hospital of Northern British Columbia (UHNBC) and an internal medicine specialist has been a significant contributor to the work of Facility Engagement (FE) since its inception -- as a local physician leader and member of the provincial Specialist Services Committee (SSC) FE Provincial Working Group.
Dr. Smith says that Facility Engagement is allieviating some challenges at UNHBC. “Administrators are responsible for making budgetary and policy decisions, and the doctors are responsible for delivering [the expenditure [through patient care]. Yet none of the groups were talking to each other, which quite obviously was not leading to useful results.”
He says that as a solution, Facility Engagement has created opportunities and incentives for increased teamwork between the doctors and administrators, who no longer work in isolation. And benefits are showing in the areas of patient care, physician communication and relationships with staff and administration.
One example involves solving difficulties of getting adequate physician coverage for hospitalized patients, as GPs need to return to their individual family practices after morning hospital rounds and may be unable to return later in the day if needed. It is a common challenge at hospitals where GPs see inpatients. “If the physician is only at the hospital between 8:00 and 10:00 a.m., it’s very hard for teamwork, planning and multi-disciplinary rounds to occur.”
“As a solution, we consulted with physicians and Northern Health to establish a General Internal Medicine unit. It is a completely new structure developed to foster internal medical care, co-led by a doctor and an administrator.”
Under this unit, internists were recruited to look after the needs of hospitalized patients, and take pressures off of other GPs. The internist is able to make multiple rounds of patient visits, and address urgent concerns when needed in the middle of the day. With clear benefits for patient care, Northern Health was more than happy to collaborate on the project, and fund and sustain the new unit. “It’s simply a better system. The patients who are sick are looked after in a better way,” says Dr. Smith.
Another area of change he emphasized as a result of Facility Engagement has been improvements in physician communication. As an example, internists and family doctors felt that each did not understand the others’ pressures and needs. “With the help of Facility Engagement they came together, expressed their concerns and agreed on a set of rules. Recently [two years later] they have found they have greatly improved communication and collaboration.”
A third area where improved collaboration is growing is within the general hospital community that includes staff and administration. Last fall, the entire hospital community convened a “Change Day” in which physicians came together with staff pledged to change something in the hospital. “For the very first time something like this happened in Prince George and it was very successful,” he says. 296 pledges were collected, placing Prince George in fifth position in the province. The main outcome of the event was broad collaboration. (please see picture of the various stakeholders involved)
Now that internal collaboration is getting better established in UNHBC, plans are underway to broaden collaborative efforts through a planning session in which all hospitals in the region would take part. “At the moment, Prince George has a lot of effect on Fort St. John for example, but the latter has no real say in Prince George.”
Dr. Smith says that Facility Engagement is a “very sensible initiative. It has increased the number of physicians who are active in hospital improvements and activities. “If you told me three years ago that we’d have 40 per cent of physicians involved, I’d say ’no way’, but it is happening. The numbers fluctuate across different teams in the hospital.”
And even though he is soon retiring Dr. Smith says that with the exciting opportunities that Facility Engagement has created, “I would love to be starting again.”
Terrace physicians build teamwork with Northern Health partners
Since January, there has been a big improvement in the relationship between the Terrace Physician Initiative Group Society (TPIGS) and their Northern Health partner, alongside other partners.
It all started when Dr. Lombard, TPIGS chair, began to meet with the Health Services Administrator, Chris Simms and Director of Care, Shirley Nichol in Northern Health on a monthly basis to discuss the development of FE work at Mills Memorial Hospital. This relationship, like any other, wasn’t without its road blocks. It took a collaborative effort from both sides to overcome pre-existing challenges.
Initially the two agreed that physician project proposals would be shared for feedback at the monthly meetings. This led to an open and mutual understanding between both the physician society and Northern Health about the projects and their implications on the site, staff and patients.
In the following months, TPIGS was faced with a challenge to implement two projects that required the participation of registered nurses. This was unanticipated and unplanned in the health authority’s annual budget – a learning that pointed out the need for closer collaboration.
As a way to initiate the needed collaboration, the TPIGS physicians, project manager, and Norther Health held a series of four meetings over the course of one week. In these meetings, Northern Health shared its strategic plan and improvement strategy to establish an understanding of priorities and possibilities, and align plans to prevent similar future challenges. TPIGS was also able to incorporate the health authority’s contributions into its own projects that were in planning stages.
The success of the team approach paved the way for a further collaborative process that was a first for both physicians and health authority. TPIGS physicians, Northern Health managers, and other partners came together at lunch meeting to discuss the integration of the physicians’ priorities with the health authority’s strategic plans for the north western region, which were displayed on the wall and reviewed by the group. Dr. Geller, TPIGS Treasurer, helped visualize how their physician-initiated projects fit into the health authority’s strategic plans. The physicians expressed their appreciation of the process and effort to respect and incorporate their priorities, and were amazed at how closely they resonated with TPIGS goals.
From its collaboration with Northern Health, TPIGS shares a few lessons that can be generalized for any healthy relationship: the earlier you start the collaboration the better, understand each other’s limitations and work around them; invest time in the planning phase to ensure future collaboration, meet regularly, whether formally or informally; align strategic plans; and seek opportunities for mutual gain.
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)
- Providence Health Care
Taking engagement and leadership to the next level
Through Facility Engagement, six physician leads are representing the voice of medical staff and working alongside senior health authority executives to carry out the organization’s new, seven-year strategic priorities and clinical and master planning. Read all about it here >
Physicians meet to explore the future of digital health in BC
"It doesn't matter what tools you are using, you can connect to peers and patients" - Dr. Douglas Kingsford
The digitization of health information is essential for us to have a sustainable health care system that can continue to provide British Columbians with quality care moving forward, says Dr. Douglas Kingsford, Chief Medical Information Officer for BC’s Provincial Digital Health Initiative.
Dr. Kingsford was a keynote panelist at the May 30 interactive 'Distinguished Speakers' dinner event hosted by the PHC Physicians and Surgeons Association (PASS) PIVOT Subcommittee. Providence physicians and CEO Fiona Dalton were joined by partners including Doctors of BC and Pathways to discuss BC’s plans for developing its digital health capabilities. It was one of many opportunities that Providence will have to collaborate and align the organization's needs, including its vision for the new St. Paul’s, with provincial and regional plans.
Dr. Kingsford, along with other panel guests, Dr. Damian Claydon-Platt - Chief Clinical Information Officer for VCH, PHC, and PHSA, and Brian Simmers - Chief Financial Officer for Providence, discussed the landscape in BC where, like in other provinces, digital health is fragmented. Health authorities, hospitals and community providers are often duplicating efforts and using systems and tools that aren’t linked together.
The Ministry of Health’s new strategy and governance for digital health across BC, along with the consolidation of regional IMIT services within PHSA, will change that. A coherent plan with short and long-term goals - and extensive collaboration among partners - will organize needs, streamline, modernize and link technologies together, and break down silos to ensure that everyone is working together to get more value for efforts. Ultimately, it will accelerate digital health capabilities in BC in a way that was not possible in the past.
A digital health ecosystem: an end to silos
Given the complexity of the health care system, there will not be a single digital health system for BC. Instead, a digital health ‘ecosystem’ will be created where data can move across the boundaries of multiple systems and vendors. “So it doesn't matter what tools you are using, you can connect to peers and patients,” says Dr. Kingsford.
Improving the exchange of clinical information will not only transform hospital-based care, it will support BC’s shift to increase comprehensive, team-based care in the community through Primary Care Networks. To be successful, physicians and multidisciplinary providers all need to be on the same page. Among other improvements, this shift aims to reduce preventable hospital visits.
Part of BC's digital health strategy also includes 'getting on top of' the explosion of direct-to-patient health empowerment tools, devices and apps in the marketplace - and determine how those fit into the medical landscape.
Importantly, there will be room for grassroots innovation to surface within the larger ecosystem. For example, if a group of physicians has an idea or need, there will be a way to propose, test and/or move it forward within the provincial/regional structure.
Over time, as digital health evolves, physicians will start to see changes in areas such as patient information systems, secure texting communication, digital access to care, advanced QI data and analytics, medical technologies and artificial intelligence. All will transform care and how patients and providers experience the system.
Meanwhile, it is still early days. Health authority and technology partners, physician and patient groups, and others will collaborate around the path forward. As a start, physicians at the PHC May 30 event focused on providing feedback to Dr. Kingsford to help inform near-term actions. They explored physician ‘pain points’ and improvements needed, and answered questions about what priorities should be tackled first.
Moving forward, PASS PIVOT, as well as the Provincial Digital Health team, will continue to provide opportunities for physicians and leaders to engage in these discussions as they evolve and represent their needs and perspectives in the collaborative process along the way. Stay tuned.
Physicians weigh into health authority's seven year plan
120+ Providence Health Care physicians engaged with the health authority to contribute priorities to the organization's 7-year strategic plan, which was released in spring 2019. Read more here >
- Vancouver Coastal Health
BC Children’s and Women’s Hospital highlights 30 FE projects
This summer, the Medical Allied Staff Engagement Society (MASES) of BC Children’s and Women’s Hospital held a Projects Day that highlighted the success 30 projects from the 2017-2019 round of Facility Engagement funding. Attendees, Hospital Administration, and fellow Investigators a glimpse into the great work being done by the MASES projects. Presentations, photos and project booklet here >
Working towards a more diverse, equitable and inclusive workplace for all physicians
Vancouver General Hospital and the Vancouver Physician Staff Association are exploring the disproportionate number of men to women in medical leadership roles within VCH.
With support of VCH, they hired a facilitator to go through an Appreciative Inquiry process. Together the group of women and men, front line staff and senior leadership came up with an action plan.
Reconnect with meaning and purpose: Tips from Dr. Stephen Swensen, Mayo Clinic
Trusted expert and internationally recognized caregiver advocate for reducing clinician fatigue and improving employee engagement, Dr. Stephen Swensen, Professor Emeritus, Mayo Clinic, met with members of the Vancouver Physician Staff Association this January. He shared lessons learned over his three-decade-long career with the Mayo Clinic.
“Many physicians are working in a state of professional distress,” stated Dr. Swensen. “This goes beyond burnout and includes PTSD, emotional exhaustion, clinical depression, moral injury, compassion fatigue, and suicidal thoughts. When you’re in this state, you’re more likely to make a medical error. You have relationship problems, addiction problems; your productivity goes down as does your level of quality of care. One of the biggest opportunities we have to improve patient care is by caring for each other.”
An ideal workplace has three elements that Dr. Swensen calls agency, coherence and camaraderie. The happiest teams at the Mayo Clinic, he said, have the agency to make decisions, feel connected to their group, and celebrate each other’s milestones.
Dr. Swensen identifies five behaviours (Leader Index Behaviours) that make for better leaders:
- They are inclusive.
- They communicate transparently.
- They value your ideas.
- They are interested in your career.
- They appreciate your work.
Mayo Clinic staff are surveyed annually on how their leaders rate in these areas. Those with low scores are coached to improve these or are moved out of leadership roles because leaders who don’t exhibit these five behaviours are causing harm to patients.
Medicine is a calling
Some people go to work every day for the paycheque; others see their career as a means to accomplish goals and receive acknowledgement of their contributions. It is common for those who choose a career in health care to also see their work as a calling, as a means of helping patients, their families and the greater community. When that sense of purpose is lost, said Dr. Swensen, physicians can develop professional distress.
“Engagement is the antipode to burnout; it connects us to meaning and purpose,” he said. “The number one driver of happiness is meaningful work so you would think health care should have the lowest rate of burnout. But sometimes we lose sight and have to be reconnected to our purpose. Coherence can do that. Coherence exists when all parts of the system fit together to form a united whole.”
To create coherence, leaders need to ask, listen and empower.
“It’s that annoying pebble in your shoe that holds you back rather than the mountain you need to climb. The research is clear that when departments work together to identify the ‘pebble’ they reduce burnout. You can apply this to Cerner. Superusers could monitor who’s using the system on weeknights and weekends and then ask them if they need assistance. A superuser can save a physician three to five hours a day by teaching them shortcuts.”
Architects rather than carpenters
The pronouns we use when we talk about our organization are a clue to how well that organization is thriving. When we think in terms of ‘us’ and ‘them’ rather than ‘we’ and ‘our,’ the institution flounders.
“If physicians are treated as partners, they behave that way,” said Dr. Swensen, who recalled how the Mayo’s chair of haematology addressed her team’s high burnout rate.
“She decided to be a leader, a champion—rather than a middle manager. Instead of saying this is what they’re telling us to do, let’s all just be carpenters, she empowered her physicians to be architects. They weren’t going to be told how to do something by people who don’t understand what they do. The team created the solutions.”
When we do our work, improve our work, and care for each other, our patients have the best doctors imaginable. Lean into tomorrow, Dr. Swensen encouraged, to see what difference you can make.
Further reading: Finding and Creating Joy in Work white paper (IHI white paper, co-authored by Dr. Swensen)
Article and photos submitted by the Vancouver Physician Staff Association (VPSA) >
Physician, heal thyself recommends Dr. Himat Vaghadia
In 2010, longtime VGH anesthesiologist Dr. Himat Vaghadia was working over 50 hours a week and was not paying attention to what his body was telling him. He had low energy, daily pain, poor sleep and was gaining weight.
“That’s not unusual for physicians who work those kinds of hours,” Dr. Vaghadia told a group of VCH staff gathered for his recent Vancouver Physician Staff Association (VPSA) wellness presentation. “A JAMA study of 7,288 doctors who work 50-plus hours a week showed that 58 per cent reported emotional exhaustion, 50 per cent reported depersonalization, 45 per cent felt burnout, and 38 per cent experienced depression. How can we provide the best patient care when we aren’t looking after ourselves?” Read the full story here
The art and science of leadership: Dr. Faisal Khosa offers inspiring words
Leadership takes many forms. That was one of the takeaways from a recent Vancouver Physician Staff Association (VPSA) Unique Lives in Medicine luncheon. The guest speaker was our colleague, Dr. Faisal Khosa, a VGH radiologist as well as an award-winning scholar, researcher, mentor and philosopher.
“What do all great leaders have in common,” Dr. Khosa challenged his audience. “They are beyond involved; they are fully committed. A good leader is like a candle that consumes itself to light a path for others.” Read full story here >
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.
Facility Engagement: What is changing?
How is Facility Engagement progressing since it was introduced four years ago?
A combination of new structures, remuneration, leadership, and administrative supports are enabling physicians to renew relationships among colleagues and with health authorities, in ways that were not possible in the past.
At least 3,600 physicians have participated 1400+ activities or projects, many in direct collaboration with their health authority regional leaders, administrators and frontline staff.
The latest UBC evaluation of the Facility Engagement initiative to March 31, 2019 found that medical staff and health authority leaders regard participation in the Facility Engagement Initiative as worthwhile.
With all of this activity - and a lot of hard work - the tide is starting to turn. A sense of optimism is fueling a growing culture of engagement across BC, with renewed teamwork and positive experiences reported by many of those involved.
Big themes: Foundation for change
“This is an exercise in relationships – setting a foundation that allows us to grow as an organization, as people, as a team, as partners in care.” – Dr. Harsh Hundal, Executive Medical Director Physician Engagement & Resource Planning, Interior Health
- Physician-to-physician communication and relationships are improving as a key step for MSAs to build a strong foundation for engagement and a medical staff voice. Physicians are connecting and meeting across sites and regions – for the first time ever in some cases – to get to know and support each other, discuss priorities and work on projects that strengthen their hospital, patient care, and personal well-being.
- Communication with health authorities is improving. At many sites, MSA working groups and physician members are regularly meeting and establishing collaborative processes with health authority administrators and leaders to discuss respective priorities, and to work on projects together.
- Physician wellness has also surfaced as a priority, with MSAs across BC initiating activities that aim to reduce the risk of burnout and support physicians to provide patient care in a healthier way. Some MSAs are now starting to elevate these efforts to an organizational, regional and system level to look at potential improvements that can reduce the risk of burnout. (Doctors of BC is further working on this priority through the Physician Burdens engagement and policy development process.)
- With the new 2019 Physician Master Agreement, Facility Engagement is also officially supporting medical staff engagement in the implementation of electronic health records, starting with Lower Mainland hospitals that are adopting the Cerner system.
There is more work to be done to achieve sustained change, and further evaluation of the Facility Engagement Initiative will to measure its ongoing impact.
Meanwhile, both physicians and health authority partners from many parts of the province report they are making headway to build trust and to make decisions together that impact their hospitals, programs, work culture and patient services. Stay tuned as this great work continues to unfold!
Read examples and successes > www.facilityengagement.ca/stories
Physician spaces: one step to avoid burnout
One the key priorities for MSAs in Facility Engagement is to improve relationships among doctors. At larger sites, many physicians don't know who their colleagues are and have not connected for years in some cases.
Having a collegial community and spaces where physicians can get to know each other, share conversations and have room to breathe not only helps doctors deal with the intense stresses of hospital work and potential burnout, it also helps with patient care.
When physicians know who's who, it is easier to ask a colleague for a consult or advice when having a patient care challenge.
In Facility Engagement, MSAs have planned a number of activities that enable physicians to connect and get to know each other, which includes carving out dedicated, quiet space for them to have a conversation, make a phone call, or just get away from the hubbub of the unit to gather their thoughts.
MSAs in BC are not alone in recognizing the value of having a physician lounge.
- READ: "Once endangered, doctor's lounge revived to battle burnout" - how physicians everywhere benefit from this key improvement to their work place to help prevent burnout.
Facility Engagement: Relationships drive change
- The Facility Engagement Initiative continues to gain momentum with 69 hospital-based physician groups now organized and leading more than 500 projects across BC. So what is energizing this activity?
Mainly, it’s relationships. My father, who was an obstetrician, worked at the tertiary care teaching hospital in Edmonton. He used to say he would not infrequently see Dr Snell—the CEO of the hospital at the time—in the hallway. If there was an issue to discuss, the two of them would just talk about it.
Today, doctors may never see the CEO or other senior executives. There’s not a one-on-one relationship anymore, for a variety of reasons. The pressure on resources, staff, and the whole system is so much greater. We can’t expect to be able to stop Dr Snell in the hallway and talk to him about our issues.
As a result, for the past few decades, physicians have felt that they’ve lost their voice. They are not always asked about critical decisions that impact patients. When concerns arise, often physicians don’t know whom to contact in the health authority structure. After asking the same question over and over, nothing changes, and they stop engaging. I experienced this personally, and have heard it consistently in surveys and interviews with hospital-based doctors.
That’s why we introduced Facility Engagement. It specifically aims to remove this barrier that doctors feel so discouraged about. It encourages health authorities and doctors to talk to each other and build relationships, and gives physicians time and more opportunity to influence decisions affecting their workplace and patient care.
We’re optimistic that Facility Engagement is creating an environment for change, but it will continue to take effort on the part of physicians and health authorities.
How will we know if it is working? When doctors are able to prioritize the issues most important to them and discuss them with the health authority, and say, “We’re organized now. We’d like to be involved.” And when the health authority comes to physicians to ask for input about their 10-year plan or important clinical decisions before they make them, and says, “We should talk to these doctors. They know what they’re doing.”
That doesn’t mean that every doctor will get what they want. But if physicians have a chance to weigh in and be involved, we will make some progress.
We also realize that doctors need to do a better job of talking to each other about their issues. Through this initiative they are doing more of that, and I hear they are enjoying it.
In my previous role as head of surgery, my colleagues and I agreed to reallocate some OR time from one surgical service to another, based on information that we discussed openly. The group that gave up the OR time realized it was not right that cancer patients from the other service were waiting longer than their own patients who had less-serious problems.
Supported by good information, we simply talked, and our patients benefited, which, in the end, is the whole point.
Facility Engagement is sponsored by the Specialist Services Committee, one of four committees representing a partnership of Doctors of BC and the BC Government. Read more about Facility Engagement progress at www.facilityengagement.ca.
—Sam Bugis, MD
Executive Director, Physician and External Affairs, Doctors of BC
(originally published in the BC Medical Journal, April 2018)