- Fraser Health
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
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
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 ever growing 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
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)
- Vancouver Coastal Health
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.
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.