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Georgia Foyer (2nd Floor)

  • Background and Approach: In 2017, the British Columbia Ministry of Health, released a suite of strategic policies outlining its vision for a well-designed, integrated health-care system that is person- and family-centred. These policies placed patients at the centre of health care. However, a specific policy on person- and family-centred health care was still needed. We set out to develop a provincial policy on the attributes, values and demonstrated behaviours of person- and family-centred health care. Led by the Ministry's Patients as Partners Initiative, a cross health-sector working group comprising of patients, caregivers and health-sector partners, conducted this project. We conducted: 1) a literature review on best practices for person- and family-centred care and commissioned a McMaster Review on "What features of person-centred models of care do patients, families and caregivers value?"; 2) an in-person focus group with patients and caregivers to identify most valued features, created personas and patient journey maps for points of intersection with the health-care system; and 3) consultations with provincial health authorities and physician organizations. Results: The literature review and McMaster review identified key values and attributes, best practices, methods of implementation, and measurement of person- and family-centred health care. Fifteen patients and caregivers participated in two focus group sessions. They identified six themes: "access to care", "informed", "self-management", "be understood and included", "team care", and "emotional support". These themes aligned with those found in the literature and informed the content of the policy through a collaborative process within the working group. The opportunities and challenges of implementing the policy were identified through regular consultations with the working group. This innovative, evidence-informed policy development process resulted in a policy that provides a definition, four core values, and demonstrated behaviours of person- and family-centredness at the direct clinical care, community and the health-system levels.
    Sirisha Asuri
    Research Officer | Ministry of Health
  • Falls prevention is at the core of Fraser Health's Injury Prevention initiatives. The Falls Prevention Mobile Clinic (FPMC) provides a personalized assessment session targeted to seniors living in the community. In the assessment session, participants have the opportunity to sit one-on-one with health professionals (pharmacist, physiotherapist, kinesiology assessment). At that time, various aspects of the senior's falls risk status are assessed and interventions are discussed. The FPMC occurs once a week across the Fraser Health Authority. The FPMC serves the more than 1.8 million people from Burnaby to Boston Bar. Therefore, the wait-time for a clinic appointment can range from 6 to 12 months.The FPMC team has been working hard to reduce wait-times for a FPMC appointment. One of the main strategies behind this campaign is ensuring the "right" people are being scheduled. Participants who are doing well (no previous falls, no problems with walking/balance) are invited to a group presentation about falls prevention. At the group presentation the 4 pillars of falls prevention (vision, medication, home safety and exercise) are discussed. Participants are also empowered to discuss falls prevention with their own health professionals (family doctor, pharmacist). On the other side of the spectrum, sometimes clients may be too "unwell" (advanced cognitive impairment, limited mobility) to attend the FPMC. For these participants, the FPMC team works with the individual to find the appropriate program that can better support them. Additionally, the FPMC team is working to track the wait-times in each city. By tracking the wait-times in the various Fraser Health cities, the FPMC team is able to offer more clinics in areas with a greater demand. While this is still in its early stages, the FPMC is starting to see a reduction in wait-times.
    Shianne Bains
    Coordinator, Quality Improvement | Fraser Health
  • Context and Relevance: 250,000-400,000 people are living with hepatitis C virus (HCV) infection in Canada. New curative direct acting antiviral (DAA) therapies have revolutionized HCV management. Micro-elimination strategies (targeting focussed groups or areas) are highly effective for optimizing the curative potential of DAAs. HCV treatment uptake in British Columbia (BC) improved dramatically with DAAs; however, a large proportion of people experiencing complex barriers to care have yet to be tested/treated. Social inequities, provider level barriers, and healthcare system inefficiencies hinder care access. Micro-elimination strategies must address upstream and downstream barriers to HCV treatment to meet the needs of these populations. Intervention: HepC-FreeBC is a movement among community groups, health care providers, and other service providers working towards improving quality of HCV care and achieving HCV elimination. To support HepC-FreeBC objectives, we developed a Continuous Quality Improvement framework for designing, implementing, and evaluating HCV micro-elimination strategies, including a Change Ideas Toolbox. The Toolbox outlines interventions to address social/systemic determinants of health of people living with HCV at each stage of the care cascade (testing, linkage to care, treatment, and cure). It draws from interventions that have demonstrably improved healthcare quality and patient outcomes, and is linked to indicators to monitor/evaluate impact within the HCV care cascade. Potential impact: Improving quality of HCV care has potential to yield positive impacts on the health system and patient wellbeing. Prior community and public health consultation will be key to HepC-FreeBC Change Ideas Toolbox's success and will ensure its versatility within multiple settings and populations. Preparation, monitoring/evaluation templates, work-flow planning, and other practical resources will be embedded to support HCV micro-elimination projects. Originality: Creation of a Change Ideas Toolbox to support HCV micro-elimination has not yet been undertaken elsewhere in Canada. Linking change ideas to HCV indicators is novel globally.
    Sofia Bartlett
    Post-Doctoral Fellow | BC Centre for Disease Control
  • Problem & Rationale: Diabetes has a rising prevalence, and is associated with significant morbidity, hospitalization, and premature mortality. There are limited resources and a lack of advanced discharge planning for patients initiated on insulin therapy in hospital. Patients wait for a Certified Diabetic Educator (CDE) to see them, resulting in prolonged hospitalizations, and often undergo diabetic teaching (and insulin self-administration) on the day of discharge leading to anxiety, risk of serious medication-related errors, and risk of readmission to hospital with diabetic-related concerns. Intervention: We developed an Insulin Teaching Toolkit (ITT) with a comprehensive approach to educate patients to measure their blood glucose, inject insulin, and recognize/treat hypoglycemia. The toolkit supplies teaching via booklets, DVDs and discussion, and equipment required for monitoring glucose and administering insulin. The focus is a checklist for patient education, completed by a multi-disciplinary team (physicians, nurses, pharmacists, dieticians and social workers). Informing of the intervention took place by a multi-modal approach (lunch-and-learn sessions, roaming in-services, surveys, and the use of incentives for engagement). Staff initiate and use the toolkit in days prior to discharge allowing patients to practice supervised self-administration of insulin and monitoring of blood glucose. This allows the development of a timely, structured and safe discharge plan with a streamlined transition to outpatient diabetes services. Challenges encountered were consistent documentation of checklist completion and engaging clinicians to initiate the ITT earlier in the hospital stay. Outcomes: Measures were captured through retrospective chart review. Process measures include the percentage of completion of the teaching checklist, and timing of toolkit/teaching initiation in relation to discharge. Outcome measures include the number of diabetic related readmissions in 30 days and length of hospitalization. Patient and staff satisfaction were assessed by survey to assess impact and experience of care for patients and care providers.
    Krystin Boyce
    Clinical Pharmacy Specialist, Emergency Medicine | Fraser Health
    Sarah Weinkam
    Clinical Nurse Educator | Fraser Health
    Reena Khurana
    Physician, Internal Medicine & Endocrinology | Fraser Health
  • Chronic obstructive pulmonary disease (COPD) is a chronic, progressive lung condition with a prevalence of 7.15% among those in Northwestern BC over 45 years old. In addition, it is the fifth leading cause of mortality in Canada and significantly burdens the healthcare system. Group Medical Visits (GMVs) were delivered to people living with COPD in Northwestern BC including Terrace and Haida Gwaii, in hopes of reducing the number of COPD-related emergency department (ED) visits. GMVs were led by a physician and respiratory therapist and spanned from December 2018-October 2019 with a total of five 90-minute sessions and 22 participants. Patient empowerment was integral to the project and topics were covered such as proper puffer technique and the importance of vaccinations in preventing COPD exacerbations and community-acquired pneumonia. Participants also received a review of their COPD care including spirometry testing and medication optimization according to the Canadian Thoracic Guidelines. Participants also received a COPD flare-up action plan. EMR data was reviewed 12 months prior to and following each GMV to track various things including the number of COPD-related ED visits and hospital admissions which will be displayed on the poster. Nineteen participants filled out evaluations and rated the GMVs an average of 9/10 and were ‘very likely’ to recommend the GMVs to others. In particular, participants found that GMVs enabled them to better understand and manage their COPD and medication regimens. One major challenge was coordinating sessions that accommodated both participants’ and physicians’ schedules. Suggestions for improvement included more frequent sessions, smoking cessation tips, and explanations of pulmonary function tests. Long-term goals include expanding GMV content and encouraging family physicians across the region to lead the GMVs to provide ongoing group support to individuals living with COPD. Further Plan-Do-Study-Act cycles are planned to target those at highest risk of COPD-related hospital visits.
    Nick Brochez
    Medical Student | University of British Columbia
  • Communication between specialists and family physicians can be challenging. Family physicians face difficulties with information flow from specialists and subsequent updating of patient records in a timely manner. It can also be unclear what information specialists would like to receive back from family physicians when medication changes are made. To address these challenges, we intend to trial a mentoring program in the Thompson Region. Specialists and family physicians will engage in care coordination of older adults by exploring the idea of shared decision making between the specialist, family physician, and patient. The intention is that an internal medicine specialist will come into a family practice to collaborate on the diagnosis, assessment, and treatment of patients in the context of the family physician's office. The internists were selected as they are an engaged group able to consult on older adults with multiple chronic comorbidities. One of the desired outcomes is an enhanced understanding of the internist's medical management decisions. Joint appointments can ensure both providers and the patient agree on the care plan, and that the medication record on the patient's profile is updated in a timely manner after the specialist consult. A major intended benefit is education for the family physician to apply to other patients. This trial is in the planning phase, but family physicians and internal medicine specialists have expressed interest. Potential barriers may be capacity, buy in from family physicians, and concerns around patient access. However, this opportunity should better prepare participating family physicians to care for older adults as the learnings can be applied in the future. This project is funded by Shared Care under the Coordinating Complex Care for Older Adults initiative. It aligns with several patient medical home service attributes and primary care network principles. We hope to begin the trial in November.
    Chelsea Brookes
    Project Lead | Thompson Region Division of Family Practice
    Alina Cribb
    Physician Lead | Thompson Region Division of Family Practice
  • When patients undergo surgical operations, they are placed in an unfamiliar, stressful environment; similarly, the process proves to be anxiety-inducing for their supporters. Further, the supporters often do not hear from the medical team until the end of the procedure and the patient exits the operating room. In our previous work, patient supporters expressed concerns regarding perceived lack of availability of the medical staff, uncertainty, and stress surrounding these situations. To address the desire for better communication and to mitigate the anxiety of the perioperative process, we propose PatientLink. PatientLink is a web-based online platform enabling secure one-way communication from the healthcare team to supporters for status updates of a patient to monitor and track the perioperative procedure as it happens. The healthcare provider creates a secure operation ID and a website link that can be shared to the patient's family and friends, including those not physically present in the waiting room. In a prospective cohort study, participants will be asked to complete a post-operative survey to evaluate PatientLink. This includes questions about any causes of anxiety or concern, experience with the online platform including a system usability scale, and communication between healthcare professionals and the patient supporters. Through this platform and subsequent study, we hope to improve the quality and experience of care among not only patients, but their supporters as well, as they navigate the surgical process. In using PatientLink, we hope to highlight the benefit of technology in medicine and the impact it can have on experiences with the healthcare system.
    Liz Burden
    Medical Student | University of British Columbia
  • Inability to complete essential care attributes to higher patient morbidity and mortality. Patient acuity, complexity and high volume admission rates challenge frontline teams to meet daily demands in achieving best practice care. Today's hospital culture inundates healthcare professionals with continuous new technical skills, increased documentation requirements while limiting staffing resources. Our community hospital requires innovative planning to address patient safety priorities and achieve optimal patient care. Our interdisciplinary collaborative approach targets oral hygiene, toileting, bathing, clean linens and clothing, clutter-free rooms and head of bed elevation. The steering committee includes nursing, physicians, allied, administration, regional practice and quality consultants, infection control, educational institutions and patient advisors. Systems improvement requires vast collaborative partnerships. This strategy includes site based, regional health authority programs and external educational institutions interventions and aligns with our health organization's quadruple aim supports a "we" culture, partners in health, new solutions, and connected care. Patient and provider experience, healthy people and fiscal value are integrated approaches. Hospital culture, clarifying inter-professional roles, accountability, and knowledge translation of optimal clinical standards to bedside care are targeted with internal and external stakeholders. The BC Patient Safety Learning System 'Patient's View' and Real Time Patient Experience audit tools will measure pre and post satisfaction. Staff satisfaction qualitative tool to be determined. Fiscal reduction in product and linen utilization; reduced Work Safe BC claim costs and a decrease in wound care referrals due to incontinence dermatitis or friction shear from improper boosting of patients with resulting lower length of stay. Reduced prevalence of patient safety priorities and infection rates will contribute to lower average length of stay and thereby reduce hours spent in the emergency department. Importantly, improved staff, patient, family satisfaction will positively enhance culture. Big changes require big thinking and transitioning from a "me" to "we" culture drives high level change.
    Jocelyn Klemes
    Clinical Nurse Educator | Fraser Health
    Joseph Lee
    Physician Hospitalist | Fraser Health
    Susanne Burns
    Clinical Nurse Specialist | Fraser Health
  • Context and Relevance In 2018 at BC Women's neonatal intensive care unit (BCW NICU) 25% of the shifts were designated surge status (defined as being >85% occupancy) and 11% of the shifts were designated diversion status (defined as being >90% occupancy). As a result patients to be admitted to BCW NICU experienced delayed access to the appropriate level of service. Our primary aim was to maintain occupancy at 85% or lower. Our secondary aims were to identify patient flow characteristics of the NICU and provide widespread awareness and consistent action during situations where high bed occupancy levels and/or acuity, and/or staffing deficits could threaten the safe continuation of services. Intervention A quality improvement team reviewed the patient flow characteristics of BCW NICU. Phase 1: (i) Collect both subjective and objective data (ii) Develop a new Standard of Work for bed management (iii) Develop communication tools aimed for both internal and external stakeholders. Phase 2: (i) Education about new standard of work, algorithms and communication tools (ii) Implement the intervention June 3rd 2019. Measurement Data obtained from PHSA Performance Measurement and Reporting Department and BCW NICU Division Shift Report. Data collected (ongoing): Percent occupancy rate per day; Number of Days (24hrs), Day shifts (12hrs); Night Shifts (12hrs) on surge and diversion pre and post intervention. Lessons Learned A revised Surge and Diversion policy facilitated awareness of roles and responsibilities and improved communication among stake holders. Current data, however, is showing a trend in 2019 of a greater percent of shifts in surge and diversion. Further data collection and analysis is needed to determine if a greater impact would be achieved if the interventions were implemented on a provincial level and incorporated maternity care.
    Michael Castaldo
    Neonatologist | BC Women's Hospital & Health Centre
    Cecilia Chow
    Program Manager | BC Women's Hospital & Health Centre
  • Despite Northern Health (NH) serving the largest geographical region in British Columbia, NH faces unique challenges in providing care for patients who require tertiary cardiac services as these services are only available in other health regions. Thus, as part of the NH Cardiac Strategy, the NH Cardiac Services Working Group was created with the aims to update existing cardiac order sets based on current evidence, educate health care professionals (HCPs) on effectively utilizing these revised order sets, and to improve the quality of cardiac care in NH. Due to the diverse geographic areas within NH including cities, smaller towns, and remote communities, developing a regional order set that is applicable to these various areas poses challenges. These challenges include navigating how to provide quality cardiac care in settings with limited or lack of access to resources, providing patient-centred care to diverse populations, striving for documents that are comprehensible to HCPs with varying levels of experience, and facilitating engagement of HCPs within different workplace cultures. Thus, this working group included multidisciplinary representatives from the three health service delivery areas of NH to ensure adequate representation and engagement across the region. Initially, the working group created a draft "Initial Chest Pain Management" order set by comparing existing order sets and obtaining feedback from working group members. Then, the draft was piloted at Mills Memorial Hospital in Terrace to obtain feedback from staff. Qualitative feedback from a total of nineteen HCPs was used to appropriately modify and optimize the order set. With the successful revision and approval of this order set by the working group, plans are in motion to apply a similar process to the "NSTEMI/UA" and "STEMI" order sets and to consider future plans to evaluate if these updated order sets contribute to an increase in patients receiving evidence-based cardiac care.
    Tony Chae
    Medical Student | University of British Columbia
  • Patient Journey Mapping evaluates a segment of healthcare delivery from a patient and family perspective to inform quality improvement activities and improve health outcomes. Cystic fibrosis (CF) is a complex disease requiring an in-depth interdisciplinary team focus. Clinic visits are frequent and often long. The impact of these visits on families with children who have CF has not been evaluated. The aim was to use patient journey mapping to understand patient experience and to support adherence to daily therapies, to decrease exacerbations and improve lung health of patients at BCCH CF Clinic,. The specific focus of the Journey Mapping session was to examine patient experience managing care in between clinic visits. The goals of the project included increasing patient participation and to gain a shared understanding of challenges families experience between clinic visits which will give the clinical team insight to better support patient and family adherence to therapies. The Patient Journey Mapping was undertaken with a small group of families. The process identified a need for more educational resources, more supports navigating the school systems to ensure health needs are supported and opportunities to optimize efficiencies in clinic to reduce length of clinic visit. In addition, families are interested in current research and what healthcare professionals learn at international conferences. The information about cutting edge therapies gives families hope. The outcomes of this quality improvement work include implementation of portable pulmonary function testing to minimize the length of clinic appointments, initiation of a peer to peer support program and provision of family education that focuses on research, best practices and innovative treatment therapies. This presentation will focus on the process of conducting Patient Journey Mapping, findings and outcomes of this quality improvement endeavor.
    Mark Chilvers
    Cystic Fibrosis Clinic Director | BC Children's Hospital
  • Fraser Health embarked on its Releasing Time to Care (RT2C) Journey in Fall 2016. RT2C builds capacity and empowers front line health care teams to conduct Plan-Do-Study-Act cycles to improve four core areas: Patient safety and reliability of care, efficiency of care, patient experience and staff well-being. One of the units selected for piloting the RT2C was 5W, a 44 funded bed complex care medical unit at Surrey Memorial Hospital. A multidisciplinary team was formed and with the guidance of clinical practice and quality improvement consultants, key performance indicators were identified within each of the four core areas. Baseline data was collected to determine the unit's current status. RT2C's real time data collection tools (Safety Crosses, Measle Maps, etc) were utilized and results were posted on the unit's 'Knowing How We're Doing Board' to visually represent the unit's improvement efforts. Weekly staff huddles were hosted to share PDSA cycles, set collaborative goals and discuss next steps. Since the commencement of RT2C on 5W, the unit has experienced a culture change. The team has ebbed and flowed through improvement apathy, changes in team compliment, and improvement gains and losses. The team has grown from three to a team of 10 engaged staff including clinical nurse educators, patient care coordinators, registered nurses, infection prevention consultants, unit manager, and more. Over the last 3 years, the 5W team has experienced improved: C. Difficile rates, Hand Hygiene Rates, Staff and Patient Satisfaction rates, Braden Scale completion audits, unit decluttering audits, organization of Verna Care products, medication fridge and the storage room. The results not only demonstrate improved performance on key clinical safety indicators but also the achievement of enhanced accountability at the unit level for providing the best quality care for patients.
    Karen Chiu
    Registered Nurse | Fraser Health
    Mandy Lindsay
    Director of Patient Experience | Fraser Health
  • Readmission rates are an important indicator of healthcare system performance. High readmission rates contribute to a higher cost to the healthcare system and represent sub-optimal health care system performance. Unplanned acute readmissions may indicate poor clinical outcomes for clients and be due to a myriad of factors including ineffective care transitions, poor access to community based services, challenges with medication adherence and individual-level vulnerabilities. Vancouver Coastal Health's (VCH) Mental Health and Substance Use (MHSU) readmission rate was 16.3% for fiscal year 2017/2018 and 14.1% for fiscal year 2018/2019, above the internal target of 13%. The VCH MHSU program prioritized reducing MHSU readmission rates as a notable area for quality improvement. The program is taking a multi-pronged approach to effectively reduce MHSU readmission rates with the goal of meeting an internal target of 13% for fiscal year 2019/2020. Early data for FY 19/20 shows a decreasing trend in readmissions rates. Actions taken to date include 1) Creation of a VCH MHSU Readmission steering committee (with representation from operational and medical leadership across the health authority), 2) Increasing the proportion of clients with a scheduled appointment in the community within 28 days (Using a Health Authority created - When I Leave Hospital Form). The form has been proven to be effective in reducing unplanned readmissions by increasing compliance of scheduled follow up appointments, and 3) A process to implement a real-time review of each readmission to determine the underlying reason(s), identify potential areas for improvement, and implement changes. The strategy to measure results for this initiative include reports measuring compliance of scheduled appointments within 28 days upon discharge and review of readmission rates per fiscal period via an organizational scorecard. Future work in development includes using data-driven strategy to target interventions for populations at high risk for an unplanned readmission.
    Sue Chong
    Clinical Nurse Specialist | Vancouver Coastal Health
    Suhail Nanji
    Regional Lead, Mental Health and Substance Use | Vancouver Coastal Health
    Mina Park
    Health Systems Planning Advisor | Vancouver Coastal Health
  • Patients with Hepatocellular cancer (HCC) require multidisciplinary care given the complexity in diagnosis and treatment. Coordinating such care can be particularly challenging for patients in remote areas of British Columbia or in centres which see few cases per year. The project aims to streamline the referral process for HCC patients to multidisciplinary Provincial Liver Tumor Rounds (LTR) to ensure all patients can be evaluated for the best treatment option(s), regardless of their geographical location. Easier access to LTR will decrease time to treatment decisions and improve patient satisfaction and outcomes. The project was scoped through current referral process mapping, review of care processes of selected patients from several health regions, and provider surveys. Patient process maps highlighted the turnaround time (TAT) from LTR referral to review was suboptimal. The survey results identified three key issues: unclear referral process, limited access to sub-specialty care, and a lack of local access to liver-directed therapy in more distant health regions. Stakeholder interviews identified information frequently missing from LTR referrals limiting complete assessment or review. Based on these findings, the following changes were made: a revised referral form (and available online) in collaboration with the LTR coordinator; a standard referral process and accompanying communication materials, accessible on the BC Cancer website; and a process to upload the LTR report to the electronic medical records. Plan-Do-Study-Act cycles involved refining the LTR referral form and the referral process, and utilizing the BC Cancer website as a communication platform. Thus far, the TAT has gradually stabilized with a mean of 7 days from referral to reporting. Another provider survey is being conducted to assess current satisfaction and identify areas for further improvement.
    Janine Davies
    Medical Oncologist | BC Cancer
    Sandra Chow
    Quality Improvement Leader, Physician Quality Improvement Program | Provincial Health Services Authority
    Chisato Ito
    Clinical Consultant, Physician Quality Improvement Program | Provincial Health Services Authority
  • Context & Relevance The purpose of obtaining best possible medication histories (BPMH) in the emergency department (ED) is usually viewed to reduce unintentional changes upon admission. The purpose of this study was to evaluate whether BMPH have additional value by evaluating whether these were also associated with a change in the medical management of patients presenting to the ED. We also sought to characterize the change, and whether medication discordance led to identification of an adverse drug event (ADE). Intervention We conducted a prospective cohort pilot study with a convenience sample of 243 patient charts in the Richmond Hospital ED. BPMH were conducted as per usual care. A medication was recorded as discordant when the PharmaNet record did not match with how the patient was taking the medication. In cases in which at least one discordant medication was identified, ED physicians were asked to complete a questionnaire which asked if the discordance had an effect on the medical management of the patient. In cases in which physicians described a change in the medical management, the presence of an ADE was evaluated by the research team. Measurement A total of 243 patients with at least one discordant medication were included. From this convenience sample, 125 questionnaires were placed on ED physicians' charts from which 70% were completed. Emergency physicians endorsed a change in medical management in 24% of cases. Of the cases in which a change in medical management was described, an ADE was identified in 90% of patients. Lessons Learned The benefits of a BPMH through improved patient management is an important quality gap that we've only begun to highlight here. Our pilot study was limited in sample size despite attempted strategies to increase questionnaire completion rate. Future research is warranted to further explore this quality gap in patient care.
    Kimberley Co
    Research Assistant & Medical Student | Vancouver Coastal Health
  • Drug Diversion: Knowledge is the first step In Canada, 18-21% of the general population, which includes healthcare workers, will meet the criteria of a substance use disorder at least once during their lifetime (Stats Can, 2018). Of healthcare workers with a substance use disorder, literature estimates 10-15% will remove narcotics, or other controlled drugs, from their workplace for personal use or for illegal distribution. This is known as drug diversion, which may negatively affect patients, staff, physicians, the healthcare system, and the person who is diverting. Over the past year, Fraser Health has been addressing drug diversion in light of a unique draft policy, protocol, and investigation process. Identification of narcotic transactions that do not meet practice standards or are outside normal parameters, triggers the Pharmacy Compliance Lead to convene an investigation team. The team includes a unit manager, clinical nurse educator, pharmacist, clinical nurse advisor, human resources, integrated protection services, and professional practice. Subjective evidence is also reviewed. The results permit the team to conclude whether the evidence suggests diversion or poor practice. If the former, the team supports the manager to address the employee, engage the regulatory college, and identify and mitigate risk factors related to drug diversion. Results from this quality improvement process have taught us that education about drug diversion, identifying drug diversion, and outlining the investigation process is necessary. As a result, education is being developed that will be delivered throughout Fraser Health. The objectives of this education include empowering employees to recognize drug diversion, to understand professional responsibility, and to know what the investigative process entails. The ultimate goal is improved patient and staff safety through increased drug diversion reporting and support for healthcare workers with substance use disorders. The presentation will focus on the lessons learned from developing and delivering drug diversion education.
    Laura Colley
    Clinical Practice Consultant | Fraser Health
  • Context: Multidisciplinary teams at a pediatric clinics annually coordinate assessments for 2200 children/youth aged 1-18. Roughly 70% receive a diagnosis of Autism Spectrum Disorder (ASD). "Next steps" regarding service options are provided. However, feedback from parents indicates that the "next steps" process is complex and often overwhelming. Measurement: To increase our understanding of the parent's perspective and needs, 64 parents completed a semi-structured questionnaire 6-9 months after their child/youth received an ASD diagnosis. The results revealed that 50% of parents perceived the Autism diagnosis as complex and overwhelming and follow-up was desired by 95% of these parent's. Their questions revolved around how to navigate multiple community agencies, apply for funds/services, learn about treatment strategies, and find/hire therapy teams. Intervention: Throughout 2017-2018, a multipronged project offered increased support to parents. The "next steps" package for families was revised, clinicians (who provide family supports) received training to expand their knowledge regarding service and treatment options, and a "follow -up" protocol was initiated 2 months post diagnosis. Connections between parents and ASD support agencies were formally facilitated. In 2019, 37 families were surveyed to measure parent's perceptions of the revised process. Results: Parents continue to report being overwhelmed by information received at the family conference (40%). However, the majority report that the revised "next steps" package is clear and provides adequate information to access funding/introduce services (83%). Roughly 90% of parents report that follow up contacts are appreciated; and, a majority are open to the diagnostic team facilitating connections between parents and community partners. Lessons Learned: Flexible and multiple strategies help provide the varying levels of support that parents require after receiving an ASD diagnosis for their child/youth. Sustainability of these processes requires endorsement by both management and the team.
    Tracy Conley
    Program Manager | Provincial Health Services Authority
    Cathy Parent
    Nurse Case Manager | Provincial Health Services Authority
  • Problem: Island Health had not audited its data on disclosure to know its accuracy, the extent with which disclosure was occurring, or the impediments to reporting disclosure. Background: Island Health uses the British Columbia Patient Safety & Learning System (BC PSLS), a web-based tool for healthcare professionals to report and learn from patient safety incidents. The objective of this project was to examine the current state of disclosure reporting at Island Health in order to clarify the need for disclosure learning and support. Aim: The aim was three fold: 1. Measure the extent to which disclosure is reported as occurring. 2. Identify the impediments to accurately reporting disclosure in PSLS. 3. Use learnings to inform approaches aimed at increasing the accuracy of reporting disclosure of serious harm and death incidents. Methods: We began by determining the proportion of patient safety incidents reported as disclosed to patient and family, then compared Island Health with provincial disclosure rates. Next, to check the reliability of the disclosure data we conducted chart audits to assess alignment between what was reported in BC PSLS and what was documented in the patient chart. Finally, we used semi-structured interviews with BC PSLS end-users to better understand their comprehension of disclosure and their experience with disclosure reporting. Results: For the most serious patient safety incidents disclosure is reported to occur in 59 - 73% of cases. We found moderate alignment between disclosure reporting in BC PSLS and patient charts. However, documentation suggests that only partial disclosure is likely in most instances. BC PSLS end-users identified a number of impediments to accurately reporting disclosure including: a limited understanding of disclosure and a lack of standardized process. Conclusions: This examination aided our understanding of the current state of disclosure reporting at Island Health including its rates, practices and areas for
    Fiann Crane
    Manager, Patient Safety Consultant Team | Island Health
  • Issue: Oxygen is a drug with potentially significant dangerous side effects for the neonatal patient population. Avoiding hypoxia is important, however, prolonged hyperoxia may also lead to oxidative stress and injury. It is essential for clinicians to appreciate inappropriate control of administered oxygen may lead to irreversible damage for the premature infant. Project: The Neonatal Intensive Care Unit (NICU) team at Victoria General Hospital planned to use oxygen histograms to monitor patient oxygenation trends and provide a communication tool for the multidisciplinary team to report objective data on patient oxygenation and respiratory status. These efforts led to the creation of an oxygen use and management guideline to better support oxygen administration and management. Results: The NICU team was able to increase the amount of time patients spent within the target oxygen saturation level. The team reported the histogram tools as an effective objective measure for communicating patient status and assessment across disciplines. Lesson Learned: Oxygen targeting is possible for this patient population and more work is required to meet our target goal. Application of a tool (histogram grading tool) with an objective and common language can assist the multidisciplinary team to communicate patient respiratory status. Next Steps: To continue examination of oxygen trends and histogram grading at daily rounds. Continue to educate point of care clinicians on interpretation and use of histogram as a tool for oxygen administration management.
    Shannon Cross
    Clinical Nurse Leader | Island Health
  • Social network analysis can be used to evaluate the structure of relationships and the speed of communication within the network. Practicing emergency medicine in rural and isolated areas mean practitioners rely on strong communication, trust, and efficiency with colleagues in referral centres. The Kootenay Boundary Emergency Medicine Network project will use social network analyses to measure pre-post changes in inter-collegial connections between primary and secondary emergency department (ED) sites. An online survey was deployed to determine baseline relationships among regional ED staff. Each ED physician and nurse was asked to rate their level of connection with every other ED physician and nurse in the region. The survey data was then imported into Gephi, a social network mapping software tool. The survey response rate was 36.4% (n=55/151) and 151 nodes (individual people) and 2,687 edges (connections among those people) were identified. Individuals were represented using unique identification numbers to protect anonymity. The average path length for the network was 1.77. The graph density, or overall closeness, was 0.12, indicating the Emergency Medicine Network was sparsely connected with room for improvement. The baseline social network results were used to inform project activities to help improve connections between EDs. Activities included regular project meetings to discuss regional issues, a regional 2-day emergency medicine network gathering, and local team-building engagements where the baseline social network analysis was discussed. A follow up social network analysis will be completed in late 2019 to determine changes in inter-collegial connections at primary and secondary ED sites. This presentation will discuss social network analysis methods and the results of the follow up analysis. Lessons learned on using social network analyses in project work will also be presented, from engagement to making results meaningful to the survey respondents.
    Leila Dale
    Quality Improvement Coordinator & Evaluator | Kootenay Boundary Division of Family Practice
    Mona Mattei
    Project Manager | Kootenay Boundary Division of Family Practice
    Bbandama Makwati
    Physician | Kootenay Boundary Division of Family Practice
  • Context: Lower Mainland Pathology and Laboratory Services (LM Lab) was formed in 2012 under PHSA, bringing together cohesive quality, administrative and information technology leadership for FH, VCH, PHC and PHSA laboratories. Within the Quality arm, opportunities to enhance shared knowledge and communication at the discipline level across regions was identified in several areas, as each discipline shares common structure, requirements, regulations and patient care considerations. Intervention: Development of several discipline specific working groups based on needs and/or existing project committees included leads and coordinators from each region. Identified opportunities included a shared Biosafety Manual, Transfusion Medicine Internal Audit program, workload unit review, and result report distribution. Four Working Groups were created: Transfusion Medicine, Anatomical Pathology, Pre/Post Analytics and Biosafety. Each group developed Terms of Reference and identifies goals; this ranges from cohesive accreditation review, development of template materials, supporting CST creation of education materials, and shared emerging scenarios. Measurement: Each group continues to develop to best fit the shared needs of the discipline, regulations and local variations. Improvements to date enhance both laboratory internal performance and, the patient and provider experience. These include the development of a multi-year internal audit schedule and audit template plan for 21 audits, aligned to multiple transfusion requirements; result report distribution updates to improve delivery of laboratory results with 34% of physicians providing an updated default address; and workload unit reviews. Lessons Learned: As with differing regions and sites, each discipline has unique needs and considerations based both on internal states and external influences. Recognizing shared opportunities and enhancing communications across sites and regions serves to build an increasingly consistent health care experience for staff, providers and patients alike. Creating space for discipline experts to co-create next steps, and enhancing operational reporting and support will permit further growth to these and future cross-regional laboratory groups.
    Jennifer Danielson
    Interim Strategic Lead, Laboratory Quality & Process Improvement | Provincial Health Services Authority
  • More than 85% of acute patients in hospital require intravenous (IV) therapy* and peripheral IV catheters (PIVCs) are most commonly used to gain vascular access.* Despite PIVC placement being common, establishing and maintaining vascular access for the intended duration of therapy is challenging,*and numerous complications are associated with it.* Up to half of PIVs don't meet their intended target due to complications that lead to premature catheter removal and replacement,* resulting in failed attempts and subsequent venous depletion.* Staff are at risk for needlestick injuries and exposure to bloodborne pathogens during PIVC insertion. A survey among nurses to explore blood exposure risk found that 46% reported at least one exposure per month during PIVC insertion.* In 2017, after having our own practice related concerns (consistent manipulation of the catheter hub, decreased compliance to hospital policies for vascular access) along with the prevalence of blood exposure during PIVC insertion we knew it was time for change. Motivated to implement best practice and improve patient outcomes, we partnered with BD to evaluate PIVC technologies that would address these clinical challenges. We prepared a cost analysis and proposal to change to an integrated IV catheter system and developed a support /conversion/education plan. We implemented the Signature Solutions program which provided tangible data, and visibility to our current vascular access practices, products, and policies. We used this baseline data to demonstrate the need for change and also to validate improvements upon reassessment one year after the new catheter technology and education were implemented. The results were outstanding and demonstrate significant improvement in clinical practice and outcomes. Lessons learned include: even good and beneficial change is hard, "Super-users" and leadership support are critical, follow-up is essential and new technologies and practice/policy improvements have a direct impact on patient outcomes.
    Erin Davidson
    Clinical Educator, Vascular Access Team | Vancouver Coastal Health
    Susan Fleming
    Director, Clinical Solutions and Services | Other (please specify)
  • UBC Health is partnering with BC Children's Hospital and BC Women's Hospital and Health Centre at the Provincial Health Services Authority to advance interprofessional collaborative practice learning opportunities. This year's project supported the development and delivery of interactive learning sessions for students, preceptors and staff from multiple disciplines to build the knowledge, skills, attitudes and values that are essential for interprofessional collaborative practice. The schedule of events focused on learning the interprofessional competencies; highlighting key resources and tools to support individuals and teams demonstrating collaborative practice; workshops that took a closer look at healthy communication and conflict, and that focused on workplace resiliency; and, simulation sessions that provided an opportunity to practice applying the learning in action. The findings and resources from these learning sessions were analyzed, evaluated, and are being disseminated. As health care becomes more complex with the impacts of technology, personalized care, specialization, access to health information and new delivery structures, it requires health care team members from all professions to think innovatively and purposefully about how to optimize patient and client care. Teams need to be skilful at collaborating to learn, assess, problem solve, and deliver coordinated care in new and innovative ways. Providing team-based care for patients is central to the transformation of health care in British Columbia.
    Carrie Krekoski
    Practice Education Manager, UBC Health | University of British Columbia
    Karen Derry
    Associate Director, Interprofessional Practice | BC Children's Hospital
    Christie Diamond
    Corporate Director, Academic Education | Provincial Health Services Authority
  • Context & Relevance: As the population ages, there is an urgent need to improve care and quality of life for older people living with frailty and support their caregivers. With 25% of Canadians over 65, and > 50% over 85 becoming frail, the time is right to innovate to deliver better care, closer to home. The Canadian Foundation for Healthcare Improvement and Canadian Frailty Network recently launched the Advancing Frailty Care in the Community (AFCC) Collaborative to support primary care practices, with patients and caregivers, to improve frailty care in the community. Intervention: This 2-year Collaborative will bring together teams from across the country to adapt four of the top Canadian frailty innovations from the 2018 CFN Frailty Matters Innovation Showcase (including Fraser Health's CARES program. Using a quality improvement approach in a primary care setting, teams will systematically identify and assess frailty in populations 75 years of age and over, with opportunistic screening for those 65 and over. Teams will then implement customized care plans for those identified as frail, in partnership with their caregivers. Potential/Actual Impact: Teams will implement practice change interventions informed by the profiled innovations, with the aim of slowing the progression of frailty and maintaining or enhancing quality of life, while decreasing caregiver burden. Originality: Instead of replicating an exact model of one of the profiled frailty innovations, teams will have an opportunity to take a "menu" approach and choose specific elements from any of the innovations across seven practice change areas that were common to all four programs: frailty identification; geriatric assessment; tailored intervention; person and family-centred care; collaborative care; and community supports. The four innovations and innovators profiled in this collaborative will also act as coaches to the participating teams - creating an opportunity to share their experience and lessons learned.
    Emilie Desmottes
    Improvement Lead | Canadian Foundation for Healthcare Improvement
  • A quality improvement project aimed to improve patient safety through the use of the Surgical Safety Checklist (SSCL) in 100 % of the surgical procedures at Surrey Memorial Hospital (SMH) and Jim Pattison Outpatient Care Surgery Center (JP). INTRODUCTION: In every surgery a series of steps must be performed correctly and mistakes may occur at any step increasing the risk of harm to patient safety. One challenge identified in the operating room is the inconsistent participation of surgical teams and the variation in SSCL utilization. Miscommunication within the operating room has led to safety concerns, where the Briefing, Pause and Debriefing are not being performed at a quality standard level. METHODS: Using the Lean Six Sigma framework to augment quality standards, several strategies have been implemented. First, the creation of working groups to hone in on issues and implement strategies that can be applied to multiple sites. The goal is to improve communication and provide education for both Doctors and Nurses. Secondly, an updated Surgical Safety Checklist Policy is being released by Fraser Health which provides clarity of the surgical team's roles and responsibilities. Lastly, continuous Audits & Surveys have been implemented to investigate the barriers to full SSCL implementation. Surveys are being conducted to gain staff feedback in order to examine the ways of mobilizing teams to increase the level of participation in the safety check process. Results: Audit results reveal that there has been 10% improvement in SSCL implementation and continued strategies to improve team participation during the three phases of the checklist will be implemented to promote and sustain the use of the SSCL. Conclusion: The overarching goal is to ensure a safe experience for patients who undergo surgery and provide a standardized communication tool for surgical teams. The teams are successfully engaging in improving safety in the OR
    Sukhman Dhaliwal
    Surgical Nurse, Surrey Memorial Hospital | Fraser Health
  • Currently, patients who present to Royal Inland Hospital (RIH) with an acute ST-elevation myocardial infarction (STEMI) are not consistently meeting the recommended first medical contact (FMC) to needle times. Pre-hospital administration of fibrinolytics has demonstrated reduced treatment times and improved clinical outcomes. This project involves the implementation of standard pre-hospital STEMI therapies in our local environment to appropriately selected patients. The aim of this project is to demonstrate that these therapies can be safely utilized in the pre-hospital setting in our local environment. This project involves a significant collaboration between BC Emergency Health Services (BCEHS) and Interior Health Authority (IHA) to optimize STEMI care. A STEMI recognition and management curriculum has been developed and delivered to paramedics from BCEHS. An evidence-based protocol has been developed for this pilot trial of 10 patients. Paramedics in the field will collaborate with the on-call Cardiologist to determine whether pre-hospital fibrinolytics should be administered. Data collection will include comparison of fibrinolytic times (symptom onset to needle time) and FMC to needle times for STEMI patients receiving therapies in hospital versus those receiving pre-hospital treatment. Data will be analyzed for numerically significant change in average fibrinolytic times and FMC to needle times. The expected outcome is a reduction in fibrinolytic times and FMC to needle times in patients suffering from a STEMI receiving pre-hospital therapies. Secondary outcomes being evaluated include length of stay and major bleeding. If this project is successful locally, this work could be a model for further collaboration between BCEHS and local health authorities to serve other rural communities in BC without access to primary PCI as a method of reperfusion. A major challenge will be determining how these therapies, which are currently beings used in hospital, will be funded in the out-of-hospital environment on a long-term basis.
    Sumandeep Dhesi
    Physician | Interior Health
    Nicki Gabers
    Medical Student | University of British Columbia
    Chase Crisfield
    Medical Student | University of British Columbia
  • Context & Relevance: In 2010, the Mental Health Commission of Canada and its Workforce Advisory Committee identified the opportunity to transform the mental health system in Canada through the integration and promotion of peer support. Peer Support Canada was created to carry on the work started by the MHCC, promoting the growth, recognition and accessibility of peer support. PSC developed a robust certification process for Family Peer Supporters that are grounded in national standards of practice. Intervention: FAMILIES saw an opportunity to further engage family caregivers with the PSC certification process. This included measurement and evaluation of Family Peer Supporters' experience, knowledge and competencies. FAMILIES Peer Specialists completed a four-year PSC certification process in 2018 to become the first (and as of today) the only PSC certified team in Canada strengthening family caregiver engagement in BC's mental health and addiction system. Potential/Actual Impact: The FAMILIES initiative has helped support greater accountability of Family Peer Supporters as well as developed greater stakeholder confidence in family peer support with an increase in referrals and knowing that the support provided is safe and effective. There has been an increase in the successful recruitment of family caregivers and greater retention of trained Family Peer Supporters. Experienced, knowledgeable and competent Family Peer Supporters are now working as FAMILIES in Residence at the UHNBC Adult Acute Psychiatry. Originality: The FAMILIES case study is included in the upcoming Best Advice Guide for [Family] Caregiver Engagement published by the Mental Health Commission of Canada in September 2019. The case study is the only example of a promising practice engaging family caregivers throughout their journey of adaptation to the trauma of mental illness. The MHCC created the Best Advice Guide to help heath-care providers involve family caregivers and recognize the crucial role they play in fostering recovery.
    Kim Dixon
    Family Peer Support Mentor | BC Schizophrenia Society
  • The quality improvement field recognizes that health care is a complex adaptive system and safety is dependent on the people and relationships within the system. Therefore, for improvements to be effective, they require engagement of people within their systems and cultures to collaboratively develop, test, and implement change. However, we continue to use a competency-based approach to develop healthcare professionals, which foregrounds individual knowledge, skills, and abilities. The concept that competencies reside in individuals and are context free is inherently paradoxical to current quality improvement thinking. Therefore, systems-level quality improvement initiatives will be working at odds with professionals who fundamentally understand their competent practice as internally located and isolated from context. In order to resolve this paradox, a novel framework for developing competence beyond the individual has been developed. The competency-based approach views competence at an individual, or micro level, that excludes the situated nature of competent practice within teams, systems, and cultures. This framework examines competence from micro, meso, and macro levels. The meso level, or activity system level, contains the context (teams and systems) for competent practice. The macro level, or cultural-historical system, contains the implicit values, rules and dispositions (culture) of the professional community of practice that structures the micro and meso levels. This framework unifies learning, organizational, and systems theories and has been preliminary researched in emergency medicine using as a single unit, embedded case study approach. This approach has the potential to better integrate quality improvement into the healthcare professional's everyday practice because it does not negate one's individual responsibilities. Instead, it illuminates the responsibilities of the team to identify the build up of coincidences, debrief error, and detect the extreme forms of performance variability that can lead to failure. It can also shine a "gentle" light on how their culture may be undermining improvement.
    Marcia Docherty
    Learning Consultant | Island Health
  • The ACS NSQIP outcome data between 2015-2018 reports patients undergoing elective open hepatectomy at Vancouver General Hospital (VGH) had a high postoperative occurrence rate of 52.6%. The NSQIP morbidity odds ratio in 2017 for major hepatectomy was 1.18 and 1.36 for partial hepatectomy. Enhanced Recovery After Surgery (ERAS) guidelines improve patient's perioperative care through evidenced based standardized documentation and patient education material. ERAS protocols have been associated with improved patient experience and outcomes for several surgical procedures at VGH. We reviewed NSQIP outcomes: transfusions, SSI, pneumonia, urinary tract infection (UTI), median length of stay (LOS) and readmissions, pre (February 2015- February 2018) N= 171 and post ERAS implementation (February 2018- June 2019) N=127, for elective open hepatectomy at VGH. A multidisciplinary team implemented the ERAS protocol in February 2018. Standardized pre-printed orders, nursing pathway and patient education booklet were created with input from perioperative multidisciplinary staff, an ERAS coordinator and patients. Adherence rate of perioperative ERAS variables were audited and reviewed at team meetings. Patients were surveyed on their experience and the education booklet. Results from audits and patient feedback were utilized for process improvements. Post ERAS implementation, decreases were seen in the rate of pneumonia from 12.3% to 7.9%, UTI's 8.8% to 7.1%, and transfusions 37.4% to 29.9%. There was a trend to more complex patients with the incidence of ASA 3 and 4 patients increased from 59.1% to 65.3% post implementation. Median LOS remained unchanged at 7 days, but readmission rates decreased from 11.1% to 7.1%. We are still striving to obtain >80% adherence to diet, mobility and anti-nausea prophylaxis. Continued education for physician, nursing and patients should be provided. ERAS information will be embedded into surgeon and surgical nursing orientation at VGH. Seeking patient feedback is integral to improving patient education material.
    Kelly Mayson
    Regional Medical Director, Quality & Safety | Vancouver Coastal Health
    Amy Myring
    ERAS Quality Improvement Coordinator | Vancouver Coastal Health
    Julie Nakahara
    Quality Improvement Coordinator, Enhanced Recovery After Surgery | Vancouver Coastal Health
  • CONTEXT & RELEVANCE: Penicillin allergies are reported in 10% of the obstetric population. When evaluated, 90% of these patients can safely receive penicillin. Withholding penicillin results in the use of broad spectrum antibiotics leading to increased rates of adverse drug reactions, resistance, cost, C. difficile infection, longer hospital stays and caesarean section (CS) surgical site infections. Finally, the influence on the neonate is unknown. During delivery 30% of women could receive penicillin for GBS prophylaxis and every woman undergoing a CS (30% of all deliveries) receives antibiotic prophylaxis prior to surgery. INTERVENTION: A Penicillin Allergy De-Labelling clinic was created as a pilot to provide access to allergy testing services for pregnant women. This was part of an education campaign about the harm of inappropriate allergy labels during childbirth. The pilot clinic will accept 77 patients in the first year. MEASUREMENT: Currently 17 women have been seen in the clinic and been safely tested. Zero patients have been allergic. Metrics for the clinic including time spent, patient flow, successful de-labelling, patient satisfaction, antibiotic use in labour, obstetrical outcomes and 3/5 year allergy status have/will be collected in REDCAP. Women's allergy status is updated using hospital systems, pharmanet, patient cards and communication with their primary care providers. Four women delivered and one received penicillin safely where an alternative antibiotic would have been prescribed. Unfortunately, a penicillin allergy was still documented in the chart despite testing in ¾ women. No adverse obstetrical outcomes were seen. LESSONS LEARNED: Extensive education is required to ensure provider and patient comfort with testing services however uptake and satisfaction has been high. Penicillin allergy testing is safe in pregnancy and provides a key point of health care contact. Further work is required on the management of the 'sticky label' which still persisted in charts despite testing being performed.
    Chelsea Elwood
    Medical Lead, Antimicrobial Stewardship | BC Women's Hospital & Health Centre
  • Cost reduction in health care is traditionally the unpleasant undertaking of upper management and is often equated to reduced services and job loss at the front line. In 2018, the Louis Brier Home and Hospital, a 215 bed long term care facility funded by Vancouver Coastal Health Authority, faced the challenge of cost-cutting because its monthly medication expenditures were constantly exceeding provincial funding. Thereby, a cost containment strategy was imperative. The following presentation describes how front-line staff took on this challenge and achieved a 20% reduction in drug costs over a 6 months period while still maintaining quality of care. Formal quality improvement methodology and appreciative inquiry were used to empower direct-care staff to achieve this seemingly insurmountable financial target. Monthly data measures (e.g. medication costs) using run charts were used to track outcomes. Successful collaboration among nursing staff, pharmacists, physicians and resident/families was achieved through regular team meetings and care conferences. Numerous change ideas were sequentially introduced including reducing medication waste, switching to lower cost (equally effective) medications and deprescribing where appropriate. This quality improvement initiative successfully reduced drug costs by 20%. The resident health outcomes tracked over the evaluation period confirmed that none of the medication changes had a negative impact on resident health outcomes. The key to the success of the initiative was the development of an effective inter-professional collaboration and resident-centered care approach.
    Diana Trejus
    Clinical Pharmacist | Other (please specify)
    Nicole Encarnacion
    Nurse Manager | Louis Brier Home & Hospital
    Denis O'Donnell
    Director of Research | Other (please specify)
  • Many persons with kidney disease do not meet physical activity guidelines. Based on findings that hospital-based group exercise programs can reduce fears and increase exercise self-efficacy, and a survey supporting patient's desire for this programming, a Renal Nordic walking (NW) program at St Paul's Hospital was developed. Working with a Patient Partner throughout the phases from design to dissemination, this study investigated the effects of a 3-month supervised Renal NW program on the fitness and quality of life of renal outpatients. Thirty participants, aged 45-84 were randomized to NW (n=15) or non-NW (n=15) groups. The NW group was offered 2 supervised NW sessions/week; the non-NW group continued their own activities. Outcome measurements at baseline and 3-month included weight, handgrip strength (HGS), 30-sec sit-to-stand test, 6-min walk test (6MWT), and Kidney Disease and Quality of Life questionnaire (KDQOL-36). Daily steps were recorded using Fitbit. Median changes in outcomes from baseline to 3-months were calculated between groups. Participants included post-renal transplant (n=10), pre-dialysis (n=14), hemodialysis (n=3), and peritoneal dialysis (n=3) patients. The NW group appeared less healthy compared to the non-NW group at baseline. However, the NW group had greater improvements in KDQOL-36 (Effect of kidney disease; p=0.021), 6MWT distance (41.5m), and HGS (1.1kg) at 3-month. A 41.5m improvement in 6MWT achieved in the NW group exceeded the Minimal Clinically Important Difference of 14.0-30.5m. Although a greater number of participants is needed to confirm these findings more confidently, these encouraging results indicate that a group-based supervised Renal NW program may provide benefits meaningful to renal outpatients. The program is now adopted by the hospital. Key messages were/are being shared via newsletters (i.e., allied health associations, Providence Health Care Communications internally & externally), general and targeted social media (i.e., Urban Poling, BC Renal Agency, Kidney Foundation of Canada), and conference abstracts & presentations.
    Dani Renouf
    Renal Resource Dietitian | Providence Health Care
  • The Canadian Foundation for Healthcare Improvement (CFHI) is a pan-Canadian organization that supports meaningful engagement of patients and families in the design, implementation, and evaluation of healthcare improvement. To-date, CFHI has supported 67 improvement teams across Canada in five different engagement collaboratives to build capacity of healthcare organizations in patient and family engagement for quality improvement, policy change, system redesign and to build engagement capable environments. CFHI has also committed to 'walk the talk' of engagement to build a culture of engagement through ongoing involvement of patient partners in all of its programs and activities. In 2017, CFHI developed the role of Patient Partner to be embedded within the organization to lead capacity building efforts of CFHI staff to enable consistent and meaningful engagement practices within our work. This Patient Partner role has been a catalyst for engagement and partnership, with increasing opportunities for patient engagement activities across CFHI programs, and importantly, a mosaic of engagement methods being used across the continuum, and particularly more collaborative models. The Patient Partner has led workshops and education sessions with staff, acted as a coach and mentor to staff in their engagement efforts, and co-designed with patient partners and staff the development of new policies surrounding contracts and agreements, guiding principles for patient and family engagement, processes for patient scholarships, and a recognition framework - all of which has deepened our engagement efforts and created consistent engagement practices within our organization. The role of an embedded Patient Partner demonstrates the visible commitment of our organization to create appropriate infrastructure that supports internal capacity of staff for consistent and meaningful engagement practices and to create an organizational culture for engagement. This innovative role may be applied by other organizations to grow their engagement efforts in order to create engagement capable environments.
    Carol Fancott
    Director, Patient & Citizen Engagement for Improvement | Canadian Foundation for Healthcare Improvement
    Angela Morin
    Patient Partner | Canadian Foundation for Healthcare Improvement
  • Patients and families often choose to share feedback about their care experience directly with staff at the point-of-care. How care providers respond to questions and concerns can have a significant impact on overall patient/family/client satisfaction. In May 2019, Fraser Health introduced the first of its kind point-of-care feedback tool. The on-line tool is part of the Patient Safety and Learning System (PSLS) and allows staff to receive and manage feedback received from patients and families at the point-of-care. The ultimate goal is to improve patient satisfaction and quality of care. The Patient Care Quality Office (PCQO) is still responsible for managing formal care quality complaints, but effectively managing complaints and concerns at the point-of-care is often all that's needed for patients and families to feel heard, and have their questions answered to their satisfaction. The two key objectives of this initiative are (1) to achieve greater consistency with how point-of-care patient/family feedback is being collected and managed across our sites, and (2) utilize a tool that staff could easily access and knew how to use. Fraser Health leaders believe that addressing patient and family concerns promptly at the point-of-care results in happier, more satisfied patients, families and staff. Point-of-Care Feedback is also a useful repository of compliments from patients and families that can be shared with staff. Along with Point-of-Care Feedback, a complementary Complaints Management Toolkit is being rolled out to promote effective communication with patients and families. Data from the first 6 months after implementation will be shared including: • Number of compliments/complaints logged into the system • Nature of compliments/complaints • Number and nature of complaints that turned into formal complaints • Feedback from staff and administrators about the tool
    Fabio Feldman
    Director, Clinical Quality & Patient Safety | Fraser Health
    Michelle Preston
    Managing Consultant, Patient Care Quality and Safety Clinical Quality & Patient Safety | Fraser Health
    Sarika Choy
    Patient Care Quality Officer | Fraser Health
    Elisabeth White
    Patient Care Quality Officer | Fraser Health
  • Introduction: The Patient to Population project applies knowledge about patient engagement methods to the population health functions of the BCCDC. The BCCDC co-leads upwards of 81 provincial working groups. Only one of these groups has embedded patient engagement in its design. The aim of this project is to increase the effectiveness of our population health planning by increasing the number of provincial working groups with active patient engagement from one to four by November 2019. Methods: A project working group has been established to represent the various professions and service areas across the BCCDC. Our methodology includes both the design of the patient engagements as well as quantitative and qualitative evaluation. This includes: • Current state analysis using process mapping and partner mapping. • Implementation using a Plan-Do-Study-Act (PDSA) approach. We are phasing our engagement approach to ensure we learn and adjust from each engagement. • Evaluation using a comparison of pre- and post- survey responses from patients and providers including both quantitative and qualitative questions. Early Findings and Conclusion: The initial engagement has shown that both clients and providers appreciated the benefits of this type of engagement in population work. All the clients and providers reported the engagement benefited the working group outcome. Early feedback also suggests the benefits include increased validity, expanding perspectives and transparency. By February, the group will have complete data to share on the three planned engagements and their impact on utilizing patient engagement methods for population health level working groups.
    Katie Fenn
    Director, Quality, Safety & Accreditation | BC Centre for Disease Control
  • Context The Physician Led Quality Improvement (PLQI) initiative at Vancouver Coastal Health (VCH) and Providence Health Care (PHC) is heading into its third year. PLQI's Level 3 training, aimed at physicians, consists of sessional funding; training in QI; support with project coordination, and data; and coaching from physician coaches. The youthfulness of the program, and high demand for its services (66 applications received, 33% acceptance rate), encourage the PLQI team to continuously improve. Intervention Opportunities for improvement were identified from "Training evaluations" by physicians, plus comments from the PLQI team during end of day debriefs on what went well and what could be improved. Changes were discussed and implemented when revising the training curriculum and during agenda preparation. For Cohort 2 (2018/19), the following changes were selected and implemented: (a) Front-loading the training. (b) Devoting more time for sharing their projects. (c) Adding new content (from recurring requests). Measurement The average level of satisfaction (Cohort 1, Cohort 2) has remained constant at 85%; while class size increased by 50%. A steady average over an increasing class size is seen as positive. Outcomes of the program for Cohort 2 showed improvements in "promoting a QI culture" (81%), and "increasing competence and confidence in leading QI" (75% and 69% respectively). Lessons learned Implementing changes to the training curriculum have resulted in unexpected consequences. Comments from staff and faculty indicated that front loading the first three sessions (one week apart) was "too much". As a result, for Cohort 3, sessions two and three have been scheduled two weeks apart. There were also unexpected benefits, e.g., some participants from the past cohort have joined the ranks as faculty for the upcoming training period. We have found value in soliciting and acting on feedback from participants, faculty, coaches, and staff when improving our training curriculum.
    Enrique Fernandez
    Program Advisor, Medical Quality | Vancouver Coastal Health
    Selina Wong
    Manager, Medical Quality | Vancouver Coastal Health
  • Hydrocephalus is a chronic neurological condition that affects around 6 in 10 000 live births and is one of the most common indications for pediatric brain surgery. The condition is fatal if left untreated, however surgical procedures such as shunt placements has led to most pediatric patients surviving and transitioning to adulthood. Unlike other chronic conditions such as cystic fibrosis, congenital heart disease, type I diabetes, etc., the transition of adolescents with hydrocephalus from pediatric to adult care is often fragmented and disjointed given the lack of attention and research in establishing appropriate guidelines and models of transfer. This is particularly concerning not only due to the prevalence of hydrocephalus among the pediatric population, but the significant increase in morbidity and mortality associated post-transition with poorly handled transfers. The purpose of the study was to quantify the various factors that challenge young adults with hydrocephalus as they go through this transitioning period by utilizing both a qualitative and quantitative approach. The study consisted of two phases that used a series of interview and survey questions to collect qualitative and quantitative data to identify factors that challenge young adults with hydrocephalus who are transitioning/transitioned into adult care. Emerging themes from the data highlighted the difficulty patients have in forgoing familiar relationships/environment and becoming self-reliant. Understanding the expectations, concerns and overall input of patients is one of the many important steps that must be taken take in order to build a foundation for a transition model of care that can carefully attend to the needs of patients with hydrocephalus.
    Saman Fouladirad
    Medical Student | University of British Columbia
  • Introduction Virtual Health uses digital innovation to connect people to care. The Office of Virtual Health (OVH) is a Provincial Health Services Authority (PHSA) initiative mandated by the BC Ministry of Health to enhance virtual care as part of the care continuum. Through clinical partnerships, OVH harnesses technology to increase equitable access to care. In 2018, OVH initiated demonstration projects to test Virtual Health technology across PHSA clinical programs. The Provincial TB Services Program (TBS) at the BC Centre for Disease Control (BCCDC) provides screening, diagnoses and treatment for patients with active and latent tuberculosis infection. This abstract describes a demonstration project identified by TBS as a Virtual Health case study. Methods The OVH formed a clinical working group to identify common Virtual Health needs across programs, then developed a process to select, implement and evaluate a technical solution. Working with OVH, TBS developed workflows and recruitment criteria, trained staff and piloted the chosen Virtual Health solution with participating patients. The evaluation utilizes the Dimensions of Quality from the BC Health Quality Matrix. Outcomes In collaboration with OVH, TBS began delivering Virtual Health patient-provider consultations in May 2019. Despite expected challenges with adapting to new technology, support for person-centred care from OVH and TBS leadership has facilitated the overall success of the demonstration project. Early feedback indicates positive patient and provider experiences. Conclusion The demonstration project is still in progress, but valuable lessons have been learned: selecting the right patient audience for the technology is important, as is the need for dedicated clinical and operational resources to support successful implementation. Additionally, feedback indicates that TB patients value the time, cost and effort saved through Virtual Health consultations, but further evaluation of clinical outcomes is needed to ensure that the same quality of patient care is provided through Virtual Health.
    Devon Haag
    Manager, Digital Public Health Services | BC Centre for Disease Control
    Ying Jiang
    Project Manager | Provincial Health Services Authority
    Katie Fenn
    Director, Quality, Safety & Accreditation | BC Centre for Disease Control
  • High intensity rehab is an evidence based intervention that can change functional outcome in many stroke survivors. At our community hospital general rehabilitation ward, it is challenging to provide adequate time for therapists to spend with patients, in order to meet the standards described by the Canadian Stroke Best Practice Guidelines. Vancouver Coastal Health and the Specialist Services Committee have provided a unique opportunity to train and support physicians to lead quality improvement initiatives in the health region. This project demonstrates one such project, which allowed increased therapy to be delivered to stroke survivors on a general rehabilitation ward. This project included a single rehab ward and used a Quality Improvement Framework to collect data and implement several PDSA (Plan, Do, Study, Act) cycles in order to generate an improved process of stroke therapy delivery. Change ideas that were implemented included reduction in required meetings attended by therapists, optimizing interdisciplinary rounds for maximum efficiency of communications between clinical staff and operations and rehab scheduling for stroke patients. Prior to the implementation of the project, stroke patients received 20-60 minutes of therapy per day, and therapists spent approximately 70 min total of their day providing direct therapy to patients. After the latest PDSA cycle, stroke patients received 60-320 minutes of therapy per day, and therapists spent approximately 200min total of their day providing therapy to patients. Using physician leadership and Quality Improvement approaches, stroke rehabilitation care can be improved without increasing resource cost to the health care system.
    Nicola Hahn
    Physician | Vancouver Coastal Health
  • Objective: Preliminary scoping review was done to understand what the barriers and facilitators are to engaging patients and families in incident investigations after an adverse event. Introduction: Adverse events occur frequently in healthcare. Although healthcare professionals speak to the importance of including patients and family in the investigation of the incident, the inclusion of patients and families is rarely done. Inclusion criteria: The population studied is patients and families involved in an adverse event. The concept studied is barriers and facilitators to involving patients and families in an incident investigation. The context is healthcare institutions. Methods: The databases of Medline, CINAHL and Psyc INFO were searched in June 2019 with limits of English language only with dates from 2010 to June 2019. The scoping review method being used is the Joanna Briggs Institute Methodology for scoping reviews. Titles and abstracts of search findings are scored by two reviewers for assessment against inclusion criteria. Full text review of the remaining studies was completed by two reviewers for assessment against inclusion criteria. Any disagreements between reviewers were settled by discussion or a third-party reviewer. Data synthesis of the studies that met inclusion criteria are presented in a table and in a narrative format. Results: The number of included studies is five. All were qualitative studies. Seventeen barriers and seven facilitators were identified in the five studies. Some of the barriers include challenges dealing with strict timelines presented by the organization, undefined roles and responsibilities of patients and families and difficulty dealing with complex issues and emotions. Patient and family engagement in incident analysis ranged from no patient engagement to consultative engagement. The participants of all studies believed that patients and families should be involved incident analysis. Conclusions: These barriers provide insight into why it can be so challenging to involve patients in incident analysis
    Kelly Helland
    Leader, Quality & Safety | BC Women's Hospital & Health Centre
  • We implemented the Synergy Workload Assessment Tool in two medicine in-patient units. Medicine has a mix of RNs, LPNs and HCAs ranging from novice to experienced providers. One of our biggest implementation challenges was additional time required for staff for tool familiarization during high patient congestion and staffing challenges. Synergy aims to increase the success of assigning the "right care provider for the right patient at the right time". Patients are assessed on a 1-5 scale for acuity and dependency. Acuity areas include vulnerability, complexity, stability and predictability while dependency comprises resiliency, resource availability, participation in care and participation in decision making. Our team will reflect on the implementation challenges and strategies chosen for success. A Synergy "champion team" was established with LPNs, RNs, Patient Care Coordinator, Clinical Nurse Educator, and a Clinical Nurse Specialist along with leadership, professional practice and BCNU support in fall 2018. Education on Synergy began in April 2019 with a soft launch in June and go-live on July 8, 2019. Plan, do, study, act cycles were implemented and frontline staff and champion team feedback was collected. Feedback was reviewed and an updated tool was implemented for staff with a new support plan. A staff satisfaction survey is being collected at baseline, three and six months. Sick time and PSLS events will also be evaluated. Successful change management strategies must integrate flexibility with clear communication in all phases of implementation. During the roll-out phase, it would be ideal if the champion team could have protected time for tool development coupled with direct individual and small group education time. Despite these challenges, there continues to be support for success and striving for the best care delivery possible by the right provider.
    Jennifer Hightower
    Patient Care Coordinator | Fraser Health
  • Communities across British Columbia are currently developing Service Plans to support the transformation of primary and community care through the implementation of Patient Medical Homes (PMHs) and Primary Care Networks (PCNs). The Innovation Support Unit (ISU) at UBC is developing a Primary and Community Care Systems Mapping (PACC-System Mapping) process that engages community organizations, primary and community care providers, and patients in an integrated, evidence-based planning process for primary and community care. The PACC System Mapping process supports communities in their development and maturation of PCNs that are aligned with patient and community needs to provide equitable primary care in all communities, including more marginalized communities and for patients with more complex care needs that require a social determinants lens. The PACC System Mapping process addresses the planning gaps identified at the community level for PCNs and communities to support the improved design. The ISU is working with the Nanaimo Division of Family Practice and the BC ACHC to co-design the mapping method and engage in mapping pilots. The results of these discussions and the recommendations report from the PACC System Mapping process will inform the implementation and evolution of Primary Care delivery in BC. Drawing preliminary findings from the Nanaimo pilot, this presentation will share the PACC-system mapping process, highlight key learnings and demonstrate the value of collaborative planning and engagement in primary care planning.
    Tiffany T. Hill
    Research Analyst | University of British Columbia
  • Background: British Columbia's Sepsis Network (BCSN) has supported ongoing improvements in the early recognition and evidence-based treatment of sepsis through (i) clinical and quality improvement (QI) resources, (ii) expert teaching and coaching, and (iii) fostering province-wide awareness and engagement. In a policy context, it is imperative to evaluate the economic impact (i.e., value for money) of BCSN to inform decisions on resource allocation for future QI strategies. Methods: A return on investment (ROI) analysis compared the financial investment in BCSN to the savings from averted sepsis cases and mortality. Aggregate data on risk-adjusted in-hospital sepsis- rates and sepsis mortality in acute care sites were obtained from the Canadian Institute for Health Information (CIHI). The BCSN implementation costs were extracted from financial reports, and the average cost of sepsis-related hospitalization was calculated from CIHI's patient cost estimator. The average cost of in-hospital death and burial costs to the family were identified from the grey literature. Results: Preliminary findings are reported for the fiscal period from April 2013 to March 2014 (baseline), and April 2014 to March 2018 (post-BCSN). Since the launch of BCSN, total program costs are estimated at $185,069. This includes development and implementation costs. Approximately 656 sepsis cases, and 119 deaths were averted in the post-BCSN period. This translates into $11,363,353 in cumulative savings from averted sepsis cases, and $2,005,297 in savings from deaths averted; altogether generating a return of $72.2 per dollar invested. Conclusions: This evaluation demonstrated a positive ROI of BCSN, and it is expected to increase if the acute care sites continue to reduce sepsis rates at least 10% without further investment. We anticipate that a broader time horizon, as well as long-term costs of sepsis survivors after hospital discharge once included in the model, will make ROI more attractive. (Additional analysis is pending final numbers)
    Eric Young
    Data Analyst | BC Patient Safety & Quality Council
    David Sweet
    Clinical Lead - Sepsis BCPSQC Chair- BC Sepsis Network VGH ICU Student/Resident/Associate Director Clinical Associate Professor, UBC | Other (please specify)
    Asif Khowaja
    Post-Doctoral Fellow | BC Patient Safety & Quality Council
  • BACKGROUND Vitamin B12 deficiency (B12D) has various non-specific manifestations including neuropsychiatric symptoms and hematologic abnormalities, which mimic common disorders among inpatients. Therefore, it is routinely ordered in the workup of various illnesses and clinical presentations. This study aims to characterize patterns and clinical utility of vitamin B12 testing in hospital, and appropriateness of repeat measurements. METHODS Patients aged ≥19 years who had ≥2 vitamin B12 tests in 2018 during admission(s) to St. Paul's Hospital (Vancouver, BC) were included in this study. Chart reviews were conducted to determine the total number of vitamin B12 tests performed in 2018 (all locations), serum vitamin B12 levels, risk factors for B12D, reason for testing, and testing intervals. RESULTS We identified 161 unique patients (101 male, 60 female) totalling a collective 487 tests, of which 440 were performed during inpatient stays. Over half (55%) of patients had ≥3 tests (range 2-9). Patients had no identifiable risk factor for B12D during 30% (91/308) of admissions. Common reasons for testing included workup of neuropsychiatric symptoms (184/440), cytopenias (168/440), and malnutrition (44/440). Biochemical deficiency was observed in only 2% (7/440) of inpatient tests. Among repeat inpatient tests, 25% (77/291) were ordered within 7 days of a previous test, 50% (145/291) in 30 days, and 75% (218/291) in 90 days. Between 50 to 83% of repeat inpatient tests were deemed unnecessary based on test intervals. CONCLUSION B12D is uncommonly seen among inpatients. Most inpatient vitamin B12 tests were performed at inappropriately short repeat intervals resulting in unnecessary lab overutilization. "Shotgun" approaches and a lack of systemic barriers to repeat or duplicate orders may be contributory. Vitamin B12 levels should only be checked if there is high clinical suspicion based on patient risk factors and absence of more likely alternative diagnoses. FUNDING None
    Janet Simons
    Medical Biochemist | Providence Health Care
    Brian Kim
    Medical Resident | University of British Columbia
  • The management of critically ill patients is complex and care practices quickly change and advance. The Intensive Care Unit (ICU) at Chilliwack General Hospital (CGH) manages a steady volume of critically ill patients; however, the unit is staffed by Internists, not the specialized Intensivists that are available at other tertiary care ICUs. This staffing model results in a significant burden on Internists and care providers at the smaller, less resourced site to 'keep up' with the quickly expanding field of critical care. It was identified that having a regular connection to an Internist to provide consultation for complex patient cases could improve both patient outcomes and provider experience. The key goals of this project were to decrease transfers and decrease the overall length of stay of ventilated patients. An iPad was placed on a stand and was used to virtually connect the ICU care team conducting rounds to an Intensivist, located in their private office or home using Skype for Business (SfB). Multidisciplinary care teams for each ICU patient identified as potentially benefiting from a consultation now work together with pooled resources to provide the highest-possible quality of care to ICU patients in smaller hospital ICUs. An evaluation plan was implemented that shows an overall decrease in length of stay for patients as well as improved provider satisfaction and capacity for decision making. Several lessons have been learned that will be taken into account for sustainability and expansion of this service. This includes addressing clinician comfort level with interacting virtually, considerations for scheduling and billing practices, procurement of equipment to allow for more flexibility of the service, and addressing support models. With the successes of this pilot it is being explored to expand the use of virtual consultations to other community ICUs within the health authority.
    Jessica Kromhoff
    Virtual Health Leader | Fraser Health
  • Background: Surgical site infections (SSIs) are morbid and costly complications of spine surgery. Understanding the impact that interventions have on reducing the risk of SSIs requires appropriate surveillance. Unfortunately, valid approaches to conducting SSI surveillance in the spine surgery population are lacking because of varying SSI case definitions and the lack of a gold-standard definition for SSIs. We aimed to assess the accuracy of 4 data sources that capture SSIs after spine surgery while estimating a measurement error-adjusted SSI incidence, without relying on a gold-standard definition. Methods: We assessed the accuracy of SSI surveillance algorithms across the following 4 data sources for patients undergoing spine surgery at the Vancouver General Hospital in 2017: 1) the discharge abstract database (DAD), 2) the National Surgical Quality Improvement Program (NSQIP) database, 3) the Infection Prevention and Control Canada (IPAC) database, and 4) the local Spine Adverse Events Severity (SAVES) database. A Bayesian latent class model was used to assess the sensitivity/specificity of each data source to identify SSI and to estimate a measurement-error adjusted incidence, without relying on a gold-standard SSI definition. Results: A total of 976 patients underwent spine surgery during the study period. The most sensitive data source was the DAD (0.77, 95% CrI 0.54,0.95), while the least sensitive was the NSQIP database (0.51, 95% CrI 0.32,0.71). The most specific data source was the IPAC database (0.997, 95% CrI 0.993,1.000), while the least specific was the DAD (0.970, 95% CrI 0.957,0.981). The measurement error-adjusted SSI incidence was 0.034 (95% CrI 0.021,0.051). Conclusion: Adjustment for the measurement error of various spine surgery SSI surveillance data sources is achievable using the accuracy measures provided in this study. Thus, high-quality spine surgery SSI surveillance and research can now be feasibly conducted in a timely fashion using the most readily available data sources to stakeholders.
    Oliver Lasry
    Spine Surgery Fellow | Vancouver Coastal Health
    John Street
    Spine Surgeon | Vancouver Coastal Health
  • Authors: Wendy Song, Tim Lau, Salomeh Shajari, Amneet Aulakh, Leslie Forrester, Nilu Partovi, Jennifer Grant Background Approximately 10% of patients report a history of penicillin allergy. Recent literature suggests cross-reactivity between cephalosporins and penicillins are due to side-chain similarities. Since cefazolin has a unique side-chain from other beta lactams, it can be safely administered in penicillin allergic patients for surgical prophylaxis. Since October 2018, our hospital updated all surgical prophylaxis pre-printed orders to use cefazolin in penicillin allergic patients, except in those with histories of cefazolin-specific allergy or delayed skin reactions (e.g. Stevens-Johnson syndrome). This study aims to retrospectively determine outcomes and safety of cefazolin as compared to other antibiotics for surgical prophylaxis in penicillin allergic patients with anaphylactic histories prior to implementation of cefazolin pre-printed orders. Methods All patients with reported anaphylactic reactions to penicillins prescribed surgical prophylaxis from October 9, 2017 to October 9, 2018 were included. Patients were stratified based on antibiotic received (i.e. cefazolin, clindamycin, vancomycin, other antibiotic) and a retrospective chart review was performed to assess for outcomes and safety. Results One-thousand-seventy-three prescriptions for prophylactic antibiotics were identified. Of these, 221 cases met inclusion with histories of anaphylaxis to pencillins: 77 (35%) cefazolin, 63 (28%) clindamycin, 33 (15%) vancomycin, and 48 (22%) other antibiotics. Amongst those receiving cefazolin, no critical incidents of allergic reactions were reported and the rates of adverse of events did not differ between any antibiotic group. Conclusion Cefazolin appears to be a safe option for surgical prophylaxis in patients with history of penicillin anaphylaxis. No differences in incidences of allergic reactions, complications or surgical delays were reported, as compared to alternate antibiotics. Further larger studies are needed to confirm our findings and determine rates of adverse events associated with the various antibiotic regimens.
    Tim Lau
    Pharmacotherapeutic Specialist, Infectious Diseases | Vancouver Coastal Health
    Jennifer Grant
    Medical Microbiologist and Infectious Diseases Physician | Vancouver Coastal Health
  • As nurses working on St. Paul's Hospital (SPH) acute care units 7ABCD, we noticed that patient perceptions of prognosis weren't always accurate, and that there was often distress at end of life as patients and families were unaware or misinformed about what was happening. We wanted to decrease this distress by increasing earlier communication with patients about their serious illnesses. Our ambidirectional (a prospective cohort with retrospective ascertainment of intervention status) design study took place at SPH 7ABCD We aimed to study an interdisciplinary approach to Serious Illness Conversations (SICs) on 7A where the Surprise Question (SQ) - "Would you be surprised if this patient died within the next year?" - was asked for patients to team members (doctors, nurses, and allied health) during interdisciplinary team care rounds, which discussed medical updates on all patients on the unit. Our objectives were to identify patients who would benefit from early SICs and study any changes in the interdisciplinary teams beliefs, confidence, and engagement in SICs. We used pre- and post-tests taken by the SPH staff, and patient chart review of patient charts from 7A and 7D. There was a significant result in a negative change for confidence in conveying serious news in the SQ group relative to the no SQ group. We found some lack of trust from healthcare providers in equating the SQ to a SIC for patients with substance abuse. The intervention of the SQ may have acted as a filtering process, leading to less engagement overall but more engagement with the right patients. Healthcare providers may have experienced moral distress due to the moral obligation of having SICs and time management issues. A paradigm shift to using the SQ and the SIC may have led to self-reflection in abilities and decreased confidence in the SQ group.
    Kathy Le
    Registered Nurse | Providence Health Care
  • Background: Early goals of care (GOC) conversations show improved patient outcomes and reduced health care costs. However, content and consistency of these discussions are been variable. Methods: We aimed to assess baseline GOC experiences and perspectives of 30 randomly selected patients from CKD and dialysis clinics across 5 health authorities in BC to inform future quality improvement initiatives, via 15 minute interviews. Outcomes: 66.7% of patients interviewed have advanced directives and living wills; this is more common in patients on dialysis (75%) than in patients with CKD (50%). Only 30% of patients had detailed discussions with their health providers about life-sustaining therapy; this varied across health authorities. Most patients did not find GOC discussions to be difficult, but preferred that providers initiated discussion at multiple time points and had more time to provide information. Conclusion: This baseline patient perspective assessment informs that there is room for improvement in the quality and timing of GOC discussions.
    Alice Wang
    Medical Student | Provincial Health Services Authority
  • Learning with Families (LWF) was designed to address barriers experienced by families in their healthcare journey that negatively impact the quality of their care with the health-system. The program aims to improve client/family-centred care by co-designing solutions caregivers to children with extra needs addressing challenges they identify and prioritize. The Family Leader works with a team of healthcare staff to build understanding and to make purposeful and meaningful changes in the delivery programs/services. The LWF program is based on three frameworks: Canadian Interprofessional Competency Framework, International Association for Public Participation and Knowledge to Action. Each of the four sessions focuses on understanding and supporting areas of concerns expressed by the Family Leader and is facilitated by a program leader. At the end of the sessions, cohorts identify key learnings, gaps and co-designs solutions to address areas with the support of a knowledge translation consultant. Following three cohorts, evaluations indicated 87.5% of participants strongly agreed their views were heard, 100% strongly agreed that they were able to express their views freely, 96% of participants intended/strongly intended to make interprofessional collaborative practice improvements. Three co-designed initiatives started, including ENGAGED tool, from results of identified gaps. The LWF program supports high quality engagement and intentions by healthcare staff to use learnings in practice and enhance the experience for clients/families. Also, the LWF program has been nominated as a Leading Practice with Accreditation Canada. "I think that hearing about healthcare experiences directly from families is incredibly powerful. In the room, I could see by the power of the family voice in engaging and educating healthcare providers and galvanizing them to think of how they could implement even little things to make a difference for families/children; like how their phone calls might be managed and responded to, or how they communicate in each care event"
    Leslie Louie
    Family Engagement Advisor | BC Children's Hospital
    Karen Derry
    Associate Director, Interprofessional Practice | BC Children's Hospital
    Katherine Pellizzari
    Family Partner | BC Children's Hospital
  • Context and relevance: The medical interview and case presentation are two key diagnostic tools regularly used by clinicians. Thus, it is critical that these skills be effectively taught in medical education. The Royal College of Surgeons in Ireland (RCSI) currently introduces teaching history-taking skills in the first semester of its Graduate Entry Medical (GEM) programme, mainly utilizing observational learning techniques, while case presentation is taught informally throughout the semester. Current literature in the field indicates that small-group roleplay may be the most effective way of teaching these skills and has produced the best outcomes of student performance by both subjective and objective measures. Intervention: A quality gap analysis revealed the need for intervention within the Clinical Competencies module, specifically in history-taking and case presentation. Subjective evaluation of student confidence and competence by a Needs Assessment survey highlighted student dissatisfaction with the current model (60%), as well as the collective desire for more frequent exposure to practicing these skills within the first semester of GEM (82.7%). Quality Improvement (QI) principles were utilized in the development of the new Clinical Competencies format, integrating small-group peer-led role play teaching methods into the pre-existing framework of the module. Potential impact: Increased student confidence and competence is expected with peer-assisted history taking and case presentation. This has far-reaching potential impact resulting in more effective medical graduates with a keen sense of professional identity, capable and confident of treating future patients in an empathic and caring manner. This will reduce the number of missed diagnosis, unsatisfied patients and unnecessary costly investigations in the clinical setting. Originality: This report outlines the proposal for a novel stepwise expansion of the model including periodic evaluation of efficacy, with the end goal of expanding to the entire medical programme at RCSI for the benefit of future clinicians and patients alike.
    Therese Lynn
    Medical Student | Royal College of Surgeons in Ireland

Regency Foyer (3rd Floor)

  • Objective: With a shift in home and community care to support people to age in place, there has been a rise in the health and care needs of those moving into long-term care (LTC). Overall, the older population entering LTC has a higher disease burden and require more intensive care. In BC, on average residents enter LTC in the last 18 months of life and because of this there is a greater need for care along the dying trajectory. In order to best support residents, families, and staff to manage these changes a shift in practice towards palliative approaches to care is necessary. Methods: A quality improvement project was implemented in four LTC locations on Vancouver Island, British Columbia to determine the best strategies for shifting scope of practice to include the provision of palliative approaches to care earlier in the dying trajectory. The project was concurrently evaluated by the research team. This article describes the evaluation as it relates to shifting practice through the introduction of key 'tools' to support change. Results: Leadership support and facility readiness for integrating changes in scope of practice are essential for success. Adopt, adapt, and embed strategies were key components in the implementation of the practice support tools: infographic poster, early identification tool, guide for goals of care plan, letter to physicians, and conversation guide. Significance of Results: Understanding local context and assuring readiness for change are fundamental to the successful integration of tools supporting practice change in the provision of a palliative approach to care in LTC. Supporting physicians to shift practice should be addressed separately from the rest of the care team.
    Della Roberts
    CNS Palliative Care Program | Island Health
    Kelli Stajduhdar
    Professor | University of Victoria
    Leah MacDonald
    Medical Director, Palliative & End-of-Life Care Program | Island Health
  • Sexual harassment in the medical field is common, and is perpetrated by peers, patients, and individuals in leadership positions. Experiences of sexual harassment are reported by approximately 30% of medical trainees and staff, with higher rates reported by women and visible minorities. Trainees, including those in Canada, are particularly vulnerable as they inhabit a position of limited power within the hierarchical structure of medicine; further, they may have a poorer understanding of how to respond to and report an incident. Sexual harassment is detrimental to recipients' physical, psychological, and professional wellbeing. It has been described by Canadian students as "confusing, upsetting, and embarrassing"; it is also reported to influence specialty selection. A recent Lancet paper outlines the potential for a "Time's Up" effort in medicine and delineates concrete strategies to address sexual harassment in the field. The proposed project intends to reduce the impact of sexual harassment experienced by medical trainees by focusing on one of these strategies: improving the adequacy and safety of the reporting process. Specifically, it will aim to improve Canadian medical trainee understanding of and satisfaction with the sexual harassment reporting process by 50% by 2025. This project will adopt a quality improvement model, addressing dimensions of quality in education (especially safety, timeliness, equity, and student-centeredness) and incorporating PDSA cycles. It will involve five facets: 1) identifying barriers to reporting sexual harassment, 2) streamlining and standardizing the reporting process across Canada, 3) incorporating early education for trainees on how to utilize the reporting process, 4) improving support for trainees during and after reporting sexual harassment, and 5) incorporation of trainee feedback. Ideally, this project will contribute to a broader effort to reduce sexual harassment within the medical field.
    Sarah MacIsaac
    Medical Student | Royal College of Surgeons in Ireland
  • Context and Relevance: Experiential workers, i.e. peer workers with lived/living experience of substance use, provide crucial services to support individuals that use drugs in overdose response situations. These situations include outreach, providing advice on reducing overdose risk, and assisting with overdose reversals, should they occur. Despite working in these stressful environments, unlike other healthcare providers and first responders, experiential workers usually lack access to institutional or occupational mental health support. Peer-led support systems are needed to create better working environments for experiential workers. Through a participatory community action process where experiential workers are core members of the project team (experiential researchers), the Peer-to-Peer (P2P) project aims to identify, implement and evaluate peer-led interventions that support experiential workers to provide optimal client care. Intervention: Eight focus groups (needs assessment) were led by experiential researchers in the lower mainland and Vancouver Island between November 2018 and March 2019. Key themes were identified from which experiential researchers designed an intervention model "rosE"; r-Recognition, o-Organizational Support, s-Skill Development, and E-for Everyone. The rosE model components are currently being piloted at two organizations. These interventions include practical strategies that can be implemented across Canada, such as photo-ID cards, meet and greet events, job description and contracts, and structured peer de-briefing. Impact: Simple and practical interventions allow experiential workers to feel their skills and knowledge are recognized; the experiential researchers are enthusiastically volunteering to develop communication tools including a video titled 'A Day in the Life of a Peer Responder'. One experiential researcher is using her artistic talents to develop a logo for rosE. Conclusion: The novel peer-led intervention, 'rosE', holds much promise in meeting the needs of experiential workers, and in turn improving their service delivery, as they continue to provide crucial services to individuals that use substances during the ongoing opioid crisis.
    Zahra Mamdani
    Consultant | BC Centre for Disease Control
    Lacey Mesley
    Research Assistant | University of Victoria
    Sophie Mckenzie
    Research Assistant | BC Centre for Disease Control
  • Stretchers used in the Emergency Departments are functional. They are easier to maneuver and allow for simpler and quicker position adjustments. However, these beds are also uncomfortable and have been a source of pressure injuries for patients. There are currently different types of mattresses for emergency stretchers available in the market with different price points and at different thickness ranging from 2 inches to 5 inches. Yet, there is essentially no data to guide purchasing practice other than those provided by the manufacturers. Emergency nurses also face many competing priorities and receive limited support and guidance on best practices to prevent pressure injuries among patients in the department. The goal of this QI exercise is to guide the purchase of the most appropriate mattress and to promote best practices in the Emergency Department at VGH to prevent pressure injuries. Data such as survey on baseline practice, pressure mapping, and cost analysis will be collected to inform recommendations on purchasing practice as well as on patient positioning. Additionally, a partnership between the Emergency Department, the Wound, Ostomy, and Continence Care Department, and occupational therapy have been formed to co-create policies and practice guidelines that supports knowledge translation and adoption of best practices. There will also be further collaboration to create a multimodal education plan that addresses the education needs of emergency staff to encourages sustainable changes. If successful, purchasing and practice recommendations identified through this project will be expanded and shared provincially.
    Jeff Wang
    NSWOC (Nurse specialized in Wound, ostomy, and continence) | Vancouver Coastal Health
    Mandy Man
    Registered Nurse & Clinician Lead, Team-Based Quality Improvement | Vancouver Coastal Health
  • The Patient Safety and Learning System (PSLS) is a web-based tool that BC's health authorities use to report and learn from patient safety incidences/good-catches/hazards identified in care delivery. Once reported, leadership reviews events to identify learning and quality improvement (QI) opportunities. Since its inception in 2008, use of the PSLS system by physicians and physician leaders has been limited, with reviews largely considered the responsibility of operational managers, nurse leaders, and clinical-coordinators. Relatively few physicians have knowledge of how to report or review events (as event handlers) in PSLS, typically being involved only in a consulting capacity. This limited involvement in reviews has affected the quality of reviews completed and the overall perception of the utility of PSLS. To increase PSLS reporting and review quality, the Island Health PSLS team has created a strategy to engage physicians and physician leaders. This focuses first on physicians as reporters and then physician leaders as event handlers. For reporters, customized tools have been developed, which included a condensed 'how-to' reporter video, and one-page hand-outs. For physician handlers, training approaches have been modified and standardized. As opposed to being consulted on reviews or given access and training on a 'when needed' basis, access to PSLS will be provided to physician leaders pro-actively when they are on-boarded, alongside 1-1 'how-to' training. This ensures that physician leaders are aware of their roles in using PSLS, understand the value of the PSLS, and are visible handlers who can be selected by physician reporters for follow-up. A PDSA of new processes has resulted in a 10.5% increase in physician handlers (April-August 2019). As physician engagement work rolls out we expect to see physician reported events increase, review timelines improve, and review quality increase as physician perspectives become increasingly integrated with operational manager perspectives in PSLS reviews.
    Leta Martin
    Coordinator, Patient Safety & Learning System | Island Health
  • Introduction: Patients with pre-existing conditions may benefit from optimization prior to surgery since they at risk for a higher incidence of complications and longer length of stays. Our aim was to identify and triage patients with modifiable risks prior to their OR date. We focused on lifestyle issues: nutrition, exercise, and smoking, as well as acquired conditions: anemia, diabetes and frailty. Method: A multidisciplinary team including anesthesiologists, surgeons, GPs, endocrinologist, nurse coordinators, physiotherapists, dieticians, and patient representatives meet over 2 years to process map the current state, and to incorporate change ideas into surgical booking process. A series of PDSA cycles were performed to trial and refine a new patient screening questionnaire which identifies patients with the above issues and then develop standard operating procedures to triage patients to specific interventions to optimize their condition. Simultaneously education material was revised to engage and activate patients in their care prior to surgery. Results: 157 patients scheduled for major abdominal oncological surgery have completed the questionnaire, and had their preoperative blood work reviewed at the time the OR booking package was submitted. 9% of patients were identified as requiring nutritional counselling , 21% were referred to social work to discuss discharge planning, and 10.2% were identified as potentially frail and hence may benefit from prehabilation. 75% of all patients had a HbA1c performed prior to surgery, with 1/3 of patients having an abnormal result-15% were diabetic, 11% pre-diabetic, and 5.1% had unrecognized diabetes 30% were identified as anemic and those with iron-deficiency anemia, were referred to the Perioperative Blood Management Program. Conclusion: Changes to our screening questionnaire and early review of the surgical booking package when received by Pre-admission Clinic, has allowed us to identify moderate to high risk patients earlier and start them on an optimization path prior to surgery.
    Kelly Mayson
    Regional Medical Director, Quality & Safety | Vancouver Coastal Health
  • Introduction: With so many data and targets within health care, it is overwhelming to decide which targets to prioritize and where to direct efforts. Competing pressures on acute sites and staff have made it difficult to focus and prioritize the work required to meet Fraser Health Patient Safety Priority (PSPs) targets and other patient level targets. This quality improvement project aimed to prioritize improvement work and focus on a few select areas to increase the likelihood that work at each site is rigorous, impactful, and sustainable. Methods: Using Lean Six Sigma's Define-Measure-Analyze-Improve-Control (DMAIC) framework, we identified available data sources related to Patient Safety Priorities and Patient Safety Learning System (PSLS) events. Instead of reviewing data in silos, we displayed all data sources on walls to view data and targets per site and unit. We reviewed data related to hospital-acquired pneumonia, hospital-acquired urinary tract infections, delirium, sepsis, MRSA, 10-hour rule, CDI, and PSLS events. Several tools were created for analysis. From a bird's eye view, this process allowed us to view data and understand how a unit was doing in one snapshot in comparison to other units. Results: We were able to identify trends and targets not met by unit and site. In consultation with site leadership, top priorities for improvement were determined for units and sites while taking into consideration targets and clinical and operational lenses. Each site identified one main PSP and one opportunity unit to focus on. Conclusions: Focusing the work in this manner facilitated rigorous and impactful improvement projects for improving patient level outcomes.
    Shannon Winters
    Consultant, Process Improvement | Fraser Health
  • Supporting community-based initiatives is one way to strengthen, and in some cases, repair research relationships. When conducting community-based research, informed consent forms are often a gatekeeper to initiating participation in research events. However, the format and the language in these can be enough to polarize participants from engaging with our work. To continue building relationships and fostering sincere research partnerships, as researchers and service providers we need to make sure that our research materials are accessible to participants at all stages of the research process. This presentation shares a consent form that was 'reimagined' for a project, Supporting Culturally Appropriate Coming of Age Resources for Urban Indigenous Youth in Care on Vancouver Island: (Re)Connecting with self-determined health and wellness.' Our consent "booklets" include watercolour paintings commissioned specifically for this project, a complimentary colour palette for text, and photographs taken in the local territory where we are working and where many of the youth are from. Being a project strongly rooted in land-based teachings this seemed like a more appropriate and thoughtful way to initiate this engagement and show our gratitude for permission to engage with it on these lands. Although this consent form booklet was tailor-made for this study and approved by the University of Victoria and Island Health's research ethics boards, we wondered if it might have broader relevance by demonstrating ways that reimagining and redesigning participant materials can enhance cultural and participant safety in research and build lasting community relationships.
    Andrea Faith Mellor
    PhD Candidate | University of Victoria
  • Context As the Canadian population lives longer, the demand for health services across the care continuum grows. At the same time the number of Long-term Care (LTC) beds per 1000 population is decreasing resulting in a LTC population with more complex care needs, in the last stages of their life, who on average live 12 months after admission. Many chronic diseases and dementia in particular, are not well recognized as terminal with the final stages of disease difficult to identify. Interventions A learning collaborative was held in September 2018 to introduce the Palliative Approach in LTC (PALm) to five Interior Health (IH) owned and operated LTC sites. A phased approached was utilised to embed a culture of quality using the Model for Improvement. Staff was provided with education such as Learning Essential Approaches to Palliative Care and Essential Conversations. Tools and resources were developed to support this shift in practice. Sites shared monthly metrics and learnings at quarterly webinars. Measurement Since September 2018, 347 residents were introduced to PALm with 287 currently receiving PALm and 60 having passed away. Early results indicate that measures of worsening pain has improved, nine or more medications has overall remained stable, and communication with staff, resident and family has increased as evidence by the Family Survey. To date 71% of staff have received palliative education with 98% of staff feeling confident in providing the PALm approach. Additionally, 60% of families have had an essential conversation with staff. Lessons Learned Competing priorities and individualized implementation to the PALm approach brought challenges which were reviewed at monthly touch base meetings. Through early identification, and providing staff with the tools and education we are shifting practice and improving the quality of life for our residents. Our next step is to spread to all other IH sites.
    Jannah Mitchell
    Quality Review Coordinator | Interior Health
    Lisa Barnard
    Quality Review Coordinator | Interior Health
  • Approximately 300 patients arrive at Providence Healthcare (PHC) with fractured hips every year. These patients are often elderly, frail and have multiple co-morbidities. Pre-operative pain management is primarily intravenous opioids which can lead to delirium, decreased level of consciousness and other medical complications including pneumonia. In-hospital mortality is high. Strong evidence in the literature shows that if patients receive a pre-operative femoral nerve block, their pain will be dramatically reduced. They require much less opioid and have better pain control while they wait for surgery. Our QI project set out to develop and implement a pathway so that anesthesiologists could assess all hip-fracture patients and perform a femoral nerve block (if appropriate) as soon as these patients were admitted. This required the involvement of many healthcare providers: emergency medicine, orthopedics, anesthesiologists, internal medicine, and the acute pain service. Our ER and ward nurses were also involved and aware of the nerve block pathway. At PHC, we have successfully begun to perform nerve blocks on many of our hip fracture patients early in their admission to hospital. We are assessing for decreases in opioid consumption and other complications. Although the pathway is in its early stages, it is gaining traction and we are hearing about great successes from individual patients. We are currently doing an audit on all patients that have had hip-fracture surgery at PHC to assess whether or not they received a pre-operative nerve block and how this impacted their pre-operative opioid consumption. We continue to monitor how the implemented pathway is working for our patients using PDSA cycles and changes are made as necessary. In future, we hope to spread this skill to our emergency physicians so even more patients can get a nerve block early in their admission to hospital.
    Trina Montemurro
    Physician | Providence Health Care
    Ian Malnis
    Medical Student | University of British Columbia
  • CONTEXT AND RELEVANCE: The reports of the Truth and Reconciliation Commission and the National Inquiry into Missing and Murdered Indigenous Women and Girls call upon health care organizations to increase the recruitment and retention of Indigenous health care providers as a key strategy to enhance the health of Indigenous populations. Recruitment and retention of Indigenous professionals into health care organizations is cited as a way to incorporate Indigenous perspectives on health and wellness and support cultural safety initiatives. This project sought to understand the experiences of Indigenous staff working at a tertiary health care centre in BC to enhance recruitment and retention initiatives. INTERVENTION: Qualitative, semi-structured, individual interviews and focus group discussions were used to explore the experiences and perspectives of Indigenous employees at our organization. A literature review and environmental scan of human resources strategies was conducted to inform this primary research. POTENTIAL IMPACT: We'll provide recommendations and action areas that have emerged from this research for leadership at our organization and discuss how these may be relevant for other health care organizations in Canada. Our early results indicate that strategic changes to leadership structures, working environments, and HR practices have the potential to create a safer, more inclusive organizational culture for Indigenous employees and to encourage Indigenous people to work within health care, thereby improving the care provided to Indigenous patients and families. ORIGINALITY: While previous research has explored Indigenous patient experiences, Indigenous employee experiences and perspectives are less well understood. This study provides a better understanding of the factors influencing Indigenous health care employee recruitment and retention in the local context. An interdisciplinary study team ensured expert input into Indigenous health, human resources, and public health. A diverse sample of interviewees captured a range of perspectives from staff working in a variety of areas and job roles.
    Neil Fowler
    Team Leader, Indigenous Health & Wellness | Providence Health Care
    Catherine Sanders
    Respiratory Therapist | Providence Health Care
  • In October of 2017, British Columbia's Children's and Women's Hospital (BCCH & BCW) moved to its new facility with a different unit layout, single-patient rooms (SPRs). Unit layout was based on SPR recommendations by the Facility Guidelines Institute (FGI), an international non-profit organization that establishes recommendations for the design of health care facilities. The research on SPRs has focused predominantly on patients' reactions to this type of geographical layout. The literature states that patients have positive reactions to SPRs, but providers have concerns, particularly nurses' physical isolation and communications disruptions; and patient visibility and monitoring. There are few publications on safety adaptations with respect to providers' SPR concerns. This presentation will provide data from a qualitative study on BCCH nurses' perceptions of challenges and successes associated with SPRs. Focus groups were conducted with nursing staff in 2019. In addition to themes related to SPR challenges and successes, this presentation will include nurse recommendations and evidence-based solutions associated with safe healthcare delivery for SPR designs. As healthcare transitions to a patient and family-centered model of care, SPRs will become the standard of care. Prioritizing staff experience as much as patient experience is critical to maintaining morale and retention. Findings from this qualitative study enhance the literature evidence and provide nurse's recommendations for optimized use of SPRs.
    Teaghan Evans
    Registered Nurse | University of British Columbia
  • Recent literature raised concerns regarding the inappropriate utilization of laboratory tests, especially emphasizing the potential for harmful impacts on patients. As appropriateness and value of care become increasingly important in healthcare, there is a growing demand to analyze lab ordering patterns. However, the sheer volume and complexity of lab data has created barriers to meeting the demand for quality data analytics in evaluating laboratory medicine appropriateness. The data analytics team at VCH has undertaken this challenge through the development of a data validation framework with interdisciplinary collaboration between lab technicians, physicians, and other analytics teams. The process included: 1) using sample cases to develop a methodology, 2) comparing front-end and back-end datasets to isolate discrepancies, 3) working with physicians to identify desired fields for future analysis, 4) determining the level of impact for variables with discrepancies, and 5) consolidating data to minimize the discrepancies. Multiple software systems were utilized to compare millions of data points. After validation, the team worked to ensure the data is accessible for evaluation of quality improvement projects (e.g. reduce unnecessary lab testing to support resource reallocation). There were two criteria for determining the "reliability" of the results of this validation. Firstly, variables were categorised into high and low impact groups based on clinical requirements. Low impact variables with high discrepancies were excluded from the validation. Secondly, the accepted threshold for discrepancies was set at 2% -- the proportion of unmatched over total number of data points. With this methodology, the lab data validation process was shortened from years to months. This process required interdisciplinary collaboration and multiple iterations in order to correctly interpret clinical data. Working through this challenge highlights the importance of advanced planning and proactive engagement with various teams. This data will help improve patient quality and lab ordering efficiency within the organization.
    Lily Nguyen
    Advisor, Medical Quality Analytics | Vancouver Coastal Health
  • CONTEXT & RELEVANCE Managed Alcohol Programs are a harm reduction approach to support people with severe alcohol use disorder by providing alcohol in a structured setting. We initiated a managed alcohol program (MAP) for inpatients at St. Paul's Hospital in Vancouver. There has been little examination of inpatient programs. We examined the patient's experience of receiving alcohol in an acute care setting. INTERVENTION Using a qualitative interpretative descriptive methodology we conducted individual interviews to gain insight into the patient experience. We enrolled participants from the general inpatient units. The criteria for enrollment included continuation of community managed alcohol program, provision of alcohol for stabilization in hospital, and ability to provide consent. MEASUREMENT Two male and three female patients participated in the study. Their mean age was 45 years (25-58). Six themes emerged in the analysis: (1) Reasons for drinking- highlighting their reasons for drinking, including financial, physical, social, and emotional; (2) 'I'm very appreciative'- indicating that patients had positive experiences with the novel treatment; (3) 'From just vibrating to calm'- discussing how MAP helped to treat withdrawal; (4) 'It's kinda like a pacifier for me'- recognizing the positive impacts on psychological health; (5) 'I have no need to go anywhere at all'- claiming that they were engaged with the treatment plan and incentivized to stay in hospital; (6) 'Might be nice to have a selection for other people'- indicating the need to have a broader selection of alcohol as part of MAP. LESSONS LEARNED This study demonstrates that participants overall had a positive experience on MAP in the hospital. Their voices can be used to inform implementation of future managed alcohol programs in similar hospital settings. More research is needed to obtain a comprehensive understanding of the process and outcomes of MAP for effective management
    Beena Parappilly
    Clinical Nurse Specialist | Providence Health Care
  • Despite the declaration of a public health emergency in 2016, British Columbia continues to be in the grips of an ongoing overdose crisis that claims as many as four lives per day. Treatment with opioid agonist therapies (OAT) has been shown to lower the risk of overdose and overdose death; however, there remain low rates of initiation and importantly, retention on OAT. To address this gap, community clinics providing addictions treatment across Vancouver Coastal Health (VCH) and Providence Health formed a Quality Improvement (QI) Collaborative in 2017 that generated new clinical processes and standards to increase OAT uptake and retention. A critical component of any QI initiative is the ability to track progress on key performance indicators (KPIs) through the use of regular reporting. By providing an information feedback loop, regular reporting helps clinicians and healthcare operations track overall progress, identify areas of improvement, and implement appropriate actions. To support the work of the addictions and primary care teams providing OAT, VCH's Decision Support department recently piloted a QI report. This report allows each clinic to track numbers and rates of their clients who are active and retained on OAT. It is also designed to enable immediate improvements in care by providing clinical information that is pertinent to client care, namely: 1) identifying clients with recently expired OAT prescriptions, who can be prioritized for follow-up efforts, and 2) clients' use of emergency and acute healthcare services to understand potentially unmet healthcare needs. Ongoing work is aimed at more closely integrating this QI report into each clinic's clinical workflows. The development of this report demonstrates the benefits that can accrue through collaboration between clinical and informatics teams, and ultimately demonstrates the utility of reporting to improve client outcomes and reduce preventable injuries and deaths.
    Mina Park
    Health Systems Planning Advisor | Vancouver Coastal Health
  • Patient handover from OR to PICU is a crucial transition point requiring a high level of coordination and communication between multiple health care providers (HCP). In the BCCH PICU, a standardized OR to PICU handover process was developed 10 years ago, however it was felt to be cumbersome leading to poor adherence to the standard. A move to a new hospital and a high level of staff turnover was felt to be contributing to increased safety concerns relating to suboptimal handover. Audits on handover revealed numerous concerns including: handover commencing prior to patient being ready (not on monitors or not safely sedated), key team members missing at the time of handover, team members unknown to one another, IV site to course checks missed and issues with infusion lines and a general lack of coordination. A cross-departmental group from OR and PICU worked together to develop an improved handover process to address these concerns. A new visual tool was created that was simplified and focused on the salient aspects of good handover. The tool is bright, simple, and employs an pneumonic "PATH-QS": P - Patient Stable and monitored, A - All teams ready?", T - "Team introduced", H - "Handover", Q - "Questions", S - "Site to Source Checks". PDSA cycles were used to roll out and refine the tool. Six months after roll out, results are encouraging. Site to source checks increased to 100% from 80%, all team members were ready 80% of the time from 69% and safety concerns reduced from 69% to 20%. Additionally, there were 10 PSLS events filed relating to handover in the one year prior to PATH-Qs inception. Since roll out there has been zero. A simplified handover tool built collaboratively can improve quality of handover between departments and improve patient safety.
    Mona Patel
    Critical Care Physician & Program Director, Pediatric Critical Care | BC Children's Hospital
    Liz Lamb
    Quality, Safety and Accreditation Leader | BC Children's Hospital
  • Background: Clinical Digital Messaging is defined as written communication, including text messaging, email, and online chat, between patients and providers. The Provincial Health Services Authority (PHSA) Office of Virtual Health (OVH) is partnering with clinical programs on a project to increase contact with patients and clients in B.C. with the goal of enhancing the quality of care. Uses of messaging include facilitating non-personal health information related conversations, appointment reminders and harm reduction mass messaging. Methods: We consolidated requirements from various clinical programs to embark on a vendor search for Clinical Digital Messaging. We worked closely with procurement to establish an innovative process that allows us to select vendors based on our own market research and create shorter term contracts with them for demonstration purposes. Partnering with clinical programs to work with the selected vendor is our next step to bring our work to fruition to enable Clinical Digital Messaging. Expected Results: This initiative will go live in winter 2019. We aim to include 5-7 clinical programs, 20-40 clinicians, and recruit 300-500 patients and clients. Our evaluation framework is aligned with the BCPSQC Quality Framework. We will be evaluating the number of providers, patients and clients participating, the engagement rate, the reduction of no-show appointments, as well as patient and provider satisfaction as key success indicators. Conclusion: Clinical Digital Messaging is the way forward to enable Virtual Health as a method of communication that patients and providers prefer. We envision facilitating connection through text messaging, email, and online chat will allow for conversations to help with the patient and client care journey. After demonstrating and evaluating this initiative, we aim to scale throughout PHSA to move towards ensuring we provide care that is patient centred using Virtual Health.
    Pooja Patel
    Project Manager | Provincial Health Services Authority
  • In British Columbia, the Patient Medical Home is defined as a family practice that operates at an ideal level to provide longitudinal patient care. It is the foundation of care delivery in an integrated system of primary and community care networks in local communities. A Patient Medical Home (PMH) has 12 attributes that define how a practice can support patients, including through team-based care. In order to measure the implementation of the PMH throughout the province, the General Practice Services Committee developed and implemented a PMH self-assessment for physicians. It has been in circulation since Autumn 2017. As of August 1st, 2019, 2086 physicians have completed the assessment, representing 34% of the 6,219 physicians in the province. We will report on the initial results of the completed PMH assessments related to physician demographics, provider satisfaction, patient access, team-based care uptake, physician network development, among others. Assessment results indicate moderate implementation of the PMH model among respondents. These results are not surprising given the early stages of PMH development and support. Strategies for increasing implementation of the PMH model among physicians and implications of PMH attainment for physicians and patients will be discussed.
    Nathan Patten
    Senior Analyst, Evaluation | General Practice Services Committee
  • Continuous bladder irrigation (CBI) is a method of removing blood from the bladder to reduce clot formation in the postoperative phase of urologic surgery. Currently CBI is controlled manually by subjective assessment by health care professionals. A draw back to the current methodology is that it can be difficult to assess the exact amount of blood within the catheter tubing, and whether it is safe to slow down the rate of irrigation. If the rate is weaned too rapidly, blood clots can form within the bladder and obstruct the catheter tubing. This causes significant pain to the patient, and requires manual irrigations, which are both time consuming to medical staff and uncomfortable for patients. We have created a preliminary device to quantify and monitor the amount of blood present in the irrigation fluid as well as the flow rate of irrigations. Our idea is that having an objective monitor will increase the safety of our current practice while increasing nursing efficiency and reducing patient morbidity. We have utilized an LED light sensor and a load cell connected to a pocket sized computer in order to gather data and present it in a meaningful way. The device will be compact and available at the bedside to assist in clinical decision making in real-time. After initial validation in select patients, we hope to increase the functionality of the device to control the flow rate, and to use the device on any patient admitted to hospital requiring CBI.
    Drew Phillips
    Resident Physician | University of British Columbia
  • BC Cancer has received CPAC funding for integrating a palliative care approach (symptom management) into cancer care, appropriate for patients diagnosed with a life-threatening illness. Research shows that an early palliative care framework provides better outcomes, and can potentially save on medical care costs. We use iPads to repeatedly gather standardized patient symptom data during ongoing cancer care. The results are graphed longitudinally, enabling quick evaluation of symptom changes and an efficient response. This pilot project involves three patient groups (metastatic breast and lung cancer, and palliative radiation patients); the Prince George Centre pilot became active in mid-July in the radiation clinics, systemic therapy is slated for late this year, Vancouver Centre will go live in early 2020. In all 6 BC Cancer Centres, we are providing training that supports an early palliative approach in all clinics: the serious illness conversation guide, and palliative care clinical skills. Clinical care staff not receiving full education can attend staff "huddles" addressing key support points. 21 measurement indicators have been developed, assessing the extent of palliative education (currently about 10% of staff), and the success and limitations of the repeat screening (e.g., number and timeliness of referrals, degree and extent of symptom and distress burden, patient symptom care experience). Staff training is on track. Patients and health care providers are finding the repeat measures useful, with preliminary data from the active clinic being used to close gaps in palliative care support and highlight strengths in the current system. "It's extra work, but we're really getting to focus on patients' care needs. It's satisfying." Multiple test-and-evaluate cycles are being used to increase responsiveness to and acceptability of the repeat screening by patients, while addressing capacity, increased service referrals, and time concerns for the repeat measures process in both the current and future-planned pilot clinics.
    Antony Porcino
    Project Manager, Early Palliative Integration into Cancer Care | BC Cancer
  • Endoscopic Retrograde Cholangiopancreatography (ERCP) is a technique used to diagnose and treat specific pathologies of the biliary or pancreatic ductal systems through the combined use of endoscopy and fluoroscopy. Kelowna General Hospital (KGH) performs close to 1,000 ERCP procedures each year. Due to recent changes in practice, ERCP procedures that were previously performed under procedural sedation are now performed under general anesthesia. This change in practice may impact outcomes for patients, resources and the healthcare team. As such, a retrospective outcomes-based analysis was performed to identify differences between patients pre- and post-procedural scores in several key metrics, including failure rates, time spent in recovery rooms, related-incident readmission rates, and mortality. The analysis consisted of (1) a review of the number of serious patient safety events recorded in PSLS for the year prior to and following the implementation of this practice change, (2) a chart review of several process metrics, efficiency indicators, and critical quality outcomes for a two-month period in the months preceding (N=158) and following (N=150) this practice change and (3) a review of referral trends available from IH's administrative database system. Key findings include: (1) a significant reduction in the number of safety events in the one year following the practice change, (2) similar or superior outcomes in the post-cohort compared to the pre-cohort regarding intraprocedural or other follow up procedural quality and safety outcomes, (3) evidence suggesting that the ERCP program is now currently serving a broader and more medically complex population than prior to this practice change, and (4) a similar overall OR utilization time and time in Post Anesthesia Recovery. In conclusion, and of relevance for other facilities across BC and Canada, these findings demonstrate this change in practice resulted in improvements in patient safety while maintaining other quality metrics.
    Thish Rajapakshe
    Project Coordinator | Interior Health
  • Context and Relevance: Migraine is the most common type of headache disorder, affecting 8.3% of Canadians. Its debilitating nature impacts quality of life, ability to work, and places financial burden on individuals, their families and community. Pharmacological treatments exist, however, they are often insufficient to reduce or prevent migraine. Previously, migraine education groups have shown to be clinically effective in reducing participant headache frequency and severity. To our knowledge pharmacist-led group appointments however, have not been conducted or evaluated. We propose the introduction of pharmacist-led migraine group appointments at the UBC Pharmacists Clinic with the aim of improving quality of care provided for migraine patients with particular focus on optimizing medications. Intervention: We aim to recruit ten migraine patients to participate over six months in three 90-minute group appointment sessions. Participants will be educated on migraines, treatment options, and behavioural recommendations and partake in self-reflection and goal setting. Surveys will be conducted before and after sessions to evaluate changes in migraine frequency and severity, medication usage, and to elucidate changes in attitudes towards migraine management. Potential Impact: Group appointments have been shown to provide support systems for patients to allow them to generate community, share challenges and experiences, gain emotional support, and develop self-efficacy in managing medical conditions. Pharmacist-led migraine group education sessions have the potential to reduce participant's feelings of isolation, migraine severity, frequency and improve medication understanding. If successful, we plan to scale-up this initiative. Originality: Pharmacist-led group appointments for migraine have not been evaluated. The UBC Pharmacists Clinic is a centre for pharmacy practice innovation and an ideal setting to pilot novel practices to advance patient care. Through incorporating a pharmacist's expertise along with the patient voice, we hope to collaborate alongside patients to transform migraine care.
    Jillian Reardon
    Clinical Pharmacist & Lecturer | University of British Columbia
  • The St John Hospital Endoscopy program, in the rural community of Vanderhoof set out to develop and implement a comprehensive quality endoscopy program within existing structures. The team had limited resources as well as a unique set of challenges that come with rural practice. The aim was to improve clinical quality and the patient/provider experience. The need for endoscopy services is growing. Screening and diagnostic endoscopies can be safely performed in rural facilities and serves to stabilize operative services. Endoscopy quality outcome and process indicators are well established, however in current state, our system cannot consistently proved timely data. The endoscopy program in Vanderhoof has been working towards Canada-Global Rating Scale (C-GRS) certification since 2015. The PQI program offered an opportunity to build on the C-GRS work with particular attention to patient access, process efficiency, information management and patient reported outcomes. Interventions: To assess the current state of our endoscopy program and understand where improvements could be made, we utilized QI methodology and tools with attention to the following: • Establishment of a collaborative quality committee • Implementation of C-GRS recommendations • Development of strategies to improve access • Improved methods for data collection and information sharing • Improved methods for patient feedback and use of the information received • Improved referral process • Provider network development Measurement: • Regularly scheduled quality committee meetings to review outcome data against established standards • Provincial benchmarks for wait times • Clinical quality indicators • Tracking of program demand and capacity • GRS action plan completion (↑ 53%) • Patient survey feedback and completion rate (↑ 50%) Lessons Learned: • Endoscopy service delivered closer to home is essential • Rural endoscopy services are high quality and can be provided safely • Rural primary and specialized services are strongly interconnected • Improvement work requires a team with dedicated resources • QI needs administrative support and an openness to change
    Sean Ebert
    Physician | Northern Health
  • Emergency physicians at Kelowna General Hospital have historically struggled to respond to abnormal microbiology results in a consistent and timely way. Results printed on paper were haphazardly left in individual physician mailboxes, resulting in misses and unacceptable delays. There was no system for documenting a response to an abnormal result. Through the physician quality improvement program, we designed a new system called the ED Microbiology Call Back. We harnessed and modified a new feature within our electronic medical records program (Meditech) and integrated the provincial medication database technology (PharmaNet). This allowed us to create an electronic list each day of filtered (abnormal) microbiology results. Each culture result in this list was linked to a patient's individual medical record. By assigning a doctor of the day to review this list, we gained the ability to almost instantly respond when a patient's culture result came back as positive. Furthermore, the new tool allows us to access a patient's Pharmanet profile within their EMR. This system allows us to see if a patient has already been prescribed an appropriate antibiotic for their abnormal microbiology culture. This new callback system also allows us to document within a patient's electronic medical record how we have responded to an abnormal microbiology result. Most importantly it allows asynchronous patient follow up whereby; Doctor B Follow-ups Patient X's results previously ordered by Doctor A, in an information technology solution visible to all ED Physicians. This PQI project demonstrates measurably improved quality, decreased risk at lower overall system cost. Within the first month of implementation we saw our response times to abnormal cultures take on average less than a day. Furthermore, significant cost savings were realized by cutting out the printing of thousands of paper results.
    Wrae Hill
    Physician Quality Improvement Leader | Interior Health
    James Reid
    Physician Emergency Department Head, Kelowna General Hospital | Interior Health
  • • The Baby-Friendly Initiative (BFI) 10 Steps is a QI outlining the minimum standards for infant feeding and maternal/newborn care recommended by the WHO, the Breastfeeding Committee for Canada and the BC Baby Friendly Network. • One of the Northern Health Perinatal Program's quality improvement priorities in NH is to support facilities/communities efforts to achieve the BFI 10 Steps standardization, with Step 1 (policy) presenting as the highest priority as indicated through a self-assessment process. • NH has a new BFI clinical practice standard to address Step 1 of the BFI framework. An opportunity presented to formulate an implementation plan with identification of knowledge translation/education to support staff in both acute care and community settings in NH - to address the policy gap problem and implementation. • The aim of the project is by April 2019, 80% of the staff and providers in Quesnel, Prince George, Fort St. John and Kitimat hospitals/communities will have awareness and understanding of the new BFI Clinical Practice Standard (policy) available on the NH Intranet through completion of an implementation module on the Learning Hub. • The intervention phase of the project involved operational teams in four sites and facilities who worked to complete the Learning Hub module, inclusive of the primary care nurses and additional interprofessional team members. • Measurement was conducted through a mid-project check-in evaluation and a collection of completion data at two time-points in the project, highlighting percentages of completion data in all 4 hospital and community settings. 4/8 staff groups met or exceeded the 80% goal in the project. Implementation audits are ongoing to identify improvements in groups. • Lessons Learned: o Implementing a regional priority at the operational level - communication and capacity o Engagement of teams through the use of webex technology - surpassing geography and costs of travel o Check-ins for accountability, evaluation and support
    Vanessa Salmons
    Executive Lead, Perinatal Program | Northern Health
  • Objective: To review diagnostic performances of ERCP modalities in evaluating suspected pancreatobiliary malignancies. Methods: Over 1,000 patient charts (3,723 ERCP procedures) in a tertiary care hospital from 2013-2017 were reviewed retrospectively. Three main ERCP techniques were analyzed: biopsy alone (BiA), brushing alone (BrA), and brushing/biopsy dual-modality approach (BrBi). The performance of these ERCP sampling methods was determined by reviewing post-sampling clinical reports, pathology reports, and diagnostic imaging reports. Overall positive and negative finding rates were compared to subsequent diagnostic techniques to calculate sensitivity, specificity, and accuracy. A literature review was carried out comparing diagnostic performances of ERCP techniques to more recent advancements in biliary tract imaging. Results: 222 patients met study criteria for a total 285 fluoroscopy-guided ERCP procedures with cytology brushing and/or tissue biopsies. 37 (17%) patients had a history of IBD, 20 (9%) a history of pancreatitis, and 5 (2%) a history of PSC. 99 (45%) patients had a mass identified on CT, 37 (17%) a history of cancer, and 23 (10%) a history of metastatic disease. 157 (71%) patients had abnormal liver enzymes and 48 (22%) abnormal lipase. 36 (13%) patients underwent BiA, 85 (29%) patients underwent BrA, and 164 (58%) patients underwent BrBi. The sensitivities, specificities, and accuracies of the three sampling techniques were, respectively: 56%, 93%, and 85% for BiA; 73%, 96%, and 83% for BrA; and 79%, 94%, and 86% for BrBi. On the literature review, SpyGlass cholangioscopy and EUS-FNA were shown to improve on conventional ERCP. Conclusion: Our study provides data on the diagnostic performance of three ERCP sampling techniques in a tertiary care hospital to determine current standard procedures and provide baseline performance statistics for ERCP. This data can be used to compare and assess the need for newer pancreatic and biliary duct imaging techniques in hopes of improving malignancy detection rates.
    Tami Lin
    Medical Student | Interior Health
  • BACKGROUND: Malnutrition is both prevalent and costly amongst the inpatient rehabilitation (rehab) population leading to increased length of stay and risk for morbidity and mortality. It also contributes to muscle function losses, which influence quality of life and patients' ability to achieve their rehab goals. Current registered dietitian (RD) assessment tools do not include an objective measure for functional status. OBJECTIVE: To identify and treat nutrition-related muscle function losses in patients admitted to three Fraser Health rehab wards located at Queen's Park Care Centre (QPCC). INTERVENTION: Based on a comprehensive literature search, hand-grip strength dynamometry was found to be correlated to nutritional and clinical outcomes. In collaboration with the occupational therapy department, a 2 stage training protocol was developed (online and in-person) and completed by the entire QPCC RD team (n=7). Hand-grip strength measures were incorporated into nutrition assessments and follow-up visits. RESULTS: Outcome data is being collected March 2019-Dec 2019 on the efficacy of training, impact on RD intervention, clinical practice uptake and utility. Preliminary results (full results to be presented at Quality Forum) show an increase in RD confidence and knowledge after training; a 25% uptake into practice and no impact on RD efficacy. Key reasons for lack of uptake include difficulty positioning patients and timing assessments around rehab activities. Seventy five percent of malnourished patients were identified to have nutrition-related muscle function losses and 73% of these patients were able to improve their muscle function with nutrition intervention. RDs reported modifying their nutrition care plans based on hand-grip strength measures and that measures were useful in motivating patients to participate in nutrition care interventions. CONCLUSION: The introduction of an objective measure of nutrition-related muscle function loss allows RDs to treat malnutrition more comprehensively. Other clinical areas should consider adopting hand-grip strength measurement into nutrition assessments.
    Rebekah Sandhu
    Registered Dietitian | Fraser Health
  • CONTEXT / RELEVANCE: Health care-associated infection (HAI) surveillance is at the core of Infection Prevention and Control (IPAC) programs. Surveillance is defined as the ongoing, systematic collection and analysis, of HAI data, closely integrated with timely information dissemination to staff who require it to take action. The surveillance system at BC Children's and BC Women's Hospitals evolved over two decades and is complex and time consuming. An analysis showed that infection control practitioners (ICPs) were spending up to 80% of their time on surveillance activities, yet there were problems with data completeness and quality. INTERVENTION: In July 2019, IPAC embarked on a significant overhaul of the surveillance system with input from team members and stakeholders. The Surveillance working group developed a project charter, then initiated a thorough systems analysis including describing the current state, analyzing processes and determining information needs in order to meet requirements for external reporting, cluster investigations, program evaluation and internal communication to stakeholders. MEASUREMENT: An inventory of surveillance activities and tools showed that there were 30 different surveillance databases (25 in current use), with overlap in content resulting in redundant data entry. A detailed process of examining each surveillance target is now underway, analyzing both current state and the ideal information requirements; this process will be executed by ICP - physician dyads, supported by the surveillance working group. LESSONS LEARNED: Systems evolve over time and tasks are often continued because "that's the way we have always done things" - it can be beneficial to examine a system in detail to understand how improvements can be made. Lack of infrastructure is a challenge. Future steps will include engaging with the broader group of stakeholders to identify their information needs, and then redesigning the system using simple and yet robust tools to improve the information quality.
    Laura Sauve
    Pediatric Infectious Diseases Specialist & Medical Lead, Infection Prevention and Control, BC Children's Hospital | BC Children's Hospital
  • The Practice Support Program (PSP) is a provincial quality improvement program of the General Practice Services Committee (GPSC). PSP builds capacity for quality improvement (QI) within primary care practices through a suite of flexible evidence-based learning opportunities and tailored in-practice supports. EMR enablement of clinical tools and resources supports practices with QI work by simplifying documentation of data informed and guideline based care as well as the review and actionability of EMR data via automated reports/dashboards in the EMR. Working strategically with key stakeholders (Doctors technology office, EMR vendors, Physicians and MOAs) PSP is undertaking a two prong strategy to support primary care practices to build QI capacity and provide data informed care by; 1. Increasing access to intuitive tools in the EMR and, 2. Implementation support (trained PSP Regional Support Teams and Peer Mentors) using a practice facilitation model to optimize the use of EMR and improve EMR data quality. This work aligns with GPSC's strategic mandate and will support physicians and teams to become PCN ready. Specifically, we expect that practices will be able to demonstrate data informed and guideline based care with increased ease and confidence, and improve provider experience. Use of PSP EMR enabled tools will also aid physicians with panel maintenance (phase 2) and demonstration preventative care (phase 3) of the GPSC panel management incentive. To date 1540 physicians have committed to the phases of panel management in BC. During a rapid fire presentation, the project team will describe the 2 prong strategy and supporting tactics; stakeholder engagement (including EMR vendor engagement), change management, resourcing and viable evaluation options.
    Kelsey Schaeffers
    Project Manager | Doctors of BC
  • Nanaimo Regional General Hospital was the first acute care site within Island Health to implement barcode scanning technology, an important component of a Closed Loop Medication System targeted at improving medication safety. Two years after go-live patient and medication scanning rates were sub-optimal at 52% and 70% respectively. The goals of this initiative were to increase barcode scanning rates at the hospital and to learn from this experience to inform regional work and future site activations. An interdisciplinary working group was created to understand barriers and to look at improvement opportunities. The team used the IHI Model of Improvement and tested change through three consecutive PDSA cycles. The first step was to engage the site through continual discussions of the 'why' behind this work and through review of the unit-level data. The second cycle was about learning how to tap into corporate resources to remove bigger systemic barriers. The third cycle was targeted at supporting individual scanning performance in a non-punitive way through follow-up conversations with nurses. Patient and medication scanning rates were monitored weekly to track progress. PSLS data was also reviewed to provide valuable insights into medication error reporting trends over time. The feedback from the operations and regional stakeholders was an important source of qualitative data. The innovative approach and collaborative teamwork led to a 23% increase in patient scanning and an 11% increase in medication scanning results. There have been important learnings around the utilization of the barcode scanning technology as well as on the process of engaging staff in a site-wide initiative. The role of leadership, visibility and use of data, teamwork, ongoing education and regional spread were identified as the most critical levers for success of this work. The team continues to monitor scanning rates and support practice change to ensure sustainability of results.
    Margarita Shabanova
    Consultant, Process Improvement | Island Health
  • Context & Relevance: Canadian primary care is predominantly funded by fee-for-service payment models, which centers around acute episodes of care. Studies suggest this may be inadequate in meeting the needs of people with chronic illness-particularly older adults. The purpose of this review was to conduct a scoping review to summarize the evidence comparing relative performance of primary care payment methods on quality of care in areas of prevention and chronic disease management relevant to middle-age and older adults. This project was completed as part of the author's MSc coursework at Queen's University. Intervention: Ovid MEDLINE, CINAHL Plus with Full Text, Academic Search Complete, and PsycINFO were searched for records from 2000-2018, screening for quantitative studies comparing primary care payment models in Canada. Studies were excluded if: the focus was not on comparing effects of payment models on quality of care measures; it was unclear which payment models were examined; or, the measures were not relevant to middle-age or older adults. Measurement: Quality measures were extracted from studies and organized into dimensions of care, ranking the relative performance of models for each measure. General performance trends were summarized descriptively based the extracted measures and key findings of included studies. Sixteen studies, all observational and largely of weak to moderate quality, were included. Salaried and capitated payment models consistently ranked best in prevention and chronic disease management. Enhanced fee-for-service models generally ranked lower, while traditional fee-for-service consistently ranked last. Lessons Learned: This review provides additional evidence to suggest that fixed payment models, like capitation or salary, are associated with higher quality preventive care and chronic disease management compared to variable payment models, like fee-for-service. These fixed payment models foster organizational structures which align with what current evidence suggests is best for aging populations; hence, provinces may benefit from such payment reforms.
    Lance Shaver
    Medical Student | University of British Columbia
  • With advances in technology and innovative medical treatments, infants who previously would have died in early infancy are living longer. These infants have significant needs in the medical system and pose challenges in coordinating care from multiple providers. The objective of our project was to engage stakeholders at BC Women's and BC Children's Hospital in implementing system-level change to champion the successful transition of infants with medical complexity into early childhood care. We organized focus group and journey mapping activities with neonatal intensive care unit (NICU) alumni parents caring for infants with medical complexity. We conducted literature searches to identify evidence-based interventions to reduce unplanned hospitalizations, circulated summaries of unmet family needs, and determined the level of stakeholder commitment on future actions. Twenty-five opportunities for improving transitions between hospital care teams were identified through engagement with families and project team members. These opportunities focused on facilitating clinical navigation, navigating community services, and improving parental mental health. Twenty-six key multidisciplinary care providers were engaged in validating the above transition gaps. Proposed solutions from stakeholders were further validated through comparisons with the literature. Specific care interventions were recommended to key healthcare decision makers, such as providing post-discharge care coordination, implementing patient-oriented discharge summaries, and facilitating access to mental health resources. Surveys were administered to measure stakeholder intention to act on solutions presented in evidence briefs and deliberative dialogues. Transitioning from NICU to community care is especially challenging for parents of infants with medical complexity. Families, care providers, and evidence reviews concur on focusing health care system efforts to improve non-technical parenting skills (e.g. self-care, stress management) and system navigation skills to improve outcomes for parents, infants, and families. We believe this engagement activity will spark action amongst stakeholders to adopt best practices leading to improvements in care for this vulnerable patient population.
    Sandesh Shivananda
    Project Lead & Medical Director, Neonatal Program | BC Women's Hospital & Health Centre
    Emily Kieran
    Neonatologist | BC Women's Hospital & Health Centre
  • Context: Low trauma vertebral (spine) compression fractures (VCF) occur spontaneously or through minor trauma such as coughing, sneezing, or a fall from standing height. They are the most common osteoporosis related fracture and result in significant pain, difficulty with activities of daily living, decrease in quality of life, prolonged disability and an increased risk of other fractures. A multi-disciplinary working group, based out of Peace Arch Hospital, has reviewed administrative data and conducted interviews with patients to identify the gaps in care faced by patients with VCFs. Lack of timely and appropriate information, delayed diagnosis and treatment, overwhelming pain, feelings of isolation/depression and prolonged disability were some of the themes highlighted by patients. Intervention: We are proposing a multi-tier approach to address these identified care gaps. We plan to create an education pamphlet for patients with a VCF to explain their diagnosis, provide pain management guidelines, and provide realistic information around what to expect during the recovery process. We will initiate post-discharge home visits to assess how they are coping at home immediately after emergency department discharge and during the first 3 weeks after their fracture. We will be doing education seminars with family physicians to better inform them around best practice management and support for these patients. We will explore ways to better inform the public about how to prevent and treat VCF in collaboration with our patient partners. Impact/Originality: The impact of VCF on patient's quality of life has received little attention and guidelines for management are vague and contradictory. This project hopes to address the special needs of VCF patients and will be evaluated with a patient journey mapping process through in-person and phone follow-up interviews, surveys of health providers and administrative data analysis to track health care utilization.
    Sonia Singh
    Project Lead | Fraser Health
    Aven Sidhu
    Research Coordinator | Fraser Health
    Cheryl Bulycz
    Patient Partner | Fraser Health
  • Purpose: Effective communication is paramount for physicians as they communicate with multiple subspecialties and patients in the process of healthcare. Novel teaching methods routed in reflective practice have been developed including the "Unconference" which is a platform for collaborative, transformative and self-directed learning. The purpose of our study was to develop, implement and evaluate an Unconference on communication for trainees, scientists, and radiologists in an academic radiology department. Methods: Using the Unconference approach, department members and associated radiology faculty selected session topics through an online survey: communicating ideas to a larger audience, communication in conflict resolution and communication with millennial learners. Following a plenary session on social media, individuals participated in a "world café" style session utilizing the three topic areas. Facilitated by content experts, small groups focused on learning through dialogue and reflection. Following the Unconference, an anonymous online survey was sent to participants to determine their opinions regarding this teaching strategy. Results: Our survey response rate was 47.9% (n=48). Radiologists stated they learned something new at the event (96%), that the event was relevant to their practice (87%), and an effective use of their time (82%). The plenary session on social media communication was ranked the most helpful (87%) and new teaching methods was rated the most helpful small group session (80%). Stated reasons included practicality, importance in millennial learners and the interactive nature of the session. Most respondents (91%) preferred to have a semi-annual Unconference event exploring topics such as medico-legal communication and novel technologies. Conclusion: Although communication is integral to academic radiology, few radiologists and associated staff receive structured teaching on this topic. Based on our study, the Unconference and World Café formats are an effective strategy for engaging an interdisciplinary medical department and may help to enable better communication with colleagues and patients.
    Rebecca Spouge
    Medical Student | University of British Columbia
  • Depending on the severity of the event, cerebral vascular accident (CVA) patients who arrive at the emergency department of the Cowichan District Hospital are either kept in the hospital for treatment, immediately transferred to Victoria for a higher level of neurological care, or discharged to follow up independently at a Stroke Clinic in Nanaimo or Victoria. Patients who are not admitted to the hospital may experience greater difficulties in accessing rehabilitation services or learning about relevant community resources. Those living in the Cowichan area face further challenges as they must find transportation to the clinic in either Victoria or Nanaimo, both of which are over 50 km away. During the recovery period from a CVA, a combination of services such as: physiotherapy, occupational therapy, speech language pathology, counselling, and many others are often very beneficial - not only to the patient but also to others involved in their recovery. In the Cowichan Valley, many of these services are available but geographically spread throughout the region. This poses additional problems to many CVA patients who have recently been required to stop driving. To investigate the many challenges facing non-admitted CVA patients in the Cowichan Valley, a survey was recently distributed to relevant patients who experienced a CVA within the last two years. Questions in the survey explored a variety of issues such as transportation, information about services, access to services, and additional comments or recommendations. Results from this survey will be discussed with the Leadership team at Cowichan District Hospital, in the hopes of determining changes that will improve access to rehabilitation services post-CVA in the Cowichan Valley.
    Evan Stefanek
    Student | Island Health
  • In Canada, new regulations associated with the Protecting Canadians from Unsafe Drugs Act (Vanessa's Law) require all hospitals to report serious adverse drug reactions (ADRs) and medical device incidents (MDIs) to Health Canada beginning December 16, 2019. BC Patient Safety & Learning System (BCPSLS) has long-supported ADR and MDI reporting. The regulations presented an opportunity for BCPSLS and other stakeholders to build on this work by collaborating to promote a consistent message and approach and lead implementation across the province. The aim is to ensure all hospitals in BC are well-positioned to comply with the regulations before they come into force. A steering committee and working groups were convened, including BCPSLS, the Ministry of Health, Health Canada, and multidisciplinary provincial representation from pharmacy, nursing, medicine, biomedical engineering, supply chain, quality, safety, and risk management. A promotional campaign to clarify requirements and encourage reporting was developed, including in-person site visits. An eLearning module, blog stories, presentations, and media kit on www.bcpslscentral.ca are available to all, including other provinces wishing to emulate BC's approach. One challenge was balancing the expansive language of government regulations with best practices for eLearning. The module focuses on need-to-know information for busy providers and is interactive and engaging. Input from the patient perspective led to inclusion of a component on patient-provider communication. The challenge of finding operational support for data management and communication with Health Canada was met by BCPSLS Central Office with resources, tools, and a toll-free reporting number to promote efficiency, consistency, compliance, and learning. Measurements include the number of reports submitted; number of staff who complete the module; website analytics; and number of sites visited. Regular collaborative meetings are scheduled into 2020 to drive continuous improvement and sustain this important initiative to improve Health Canada's ability to identify and reduce risks to Canadians.
    Kim Steger
    Communications Specialist | BC Patient Safety & Learning System
  • Patient reported outcome (PROs) are gaining popularity in various medical disciplines as a mechanism to improve accountability and overall quality of healthcare services. PROs are useful tools to characterize the specifics of symptoms, symptom burden and quality of life. Many medical guidelines for surgical procedures do not discuss specifics of recovery or establish timelines of symptom presentation. By utilizing PROs in post-operative patients, this work aims to establish a more accurate estimation of expected symptoms and timelines for symptom recovery in renal transplant recipients. Post-operative kidney transplant patients at Vancouver General Hospital were recruited (n=51) to complete post-operative recovery surveys over a six month period. The survey was designed to track symptom occurrence and recovery progress. Symptoms were categorized into groups: urologic-specific (blood in the urine, difficulty urinating, incontinence), wound healing (incision redness, swelling, fluid drainage, pain), post-operative recovery (time to first walk, diet), mental well-being, and return to normal activity (energy level, sexual activity, return to work). Common post-operative concerns among patients include graft rejection, sleep, pain, fluid overload, and bowel movements. Initial results show that 90% (n=38) of patients continue to report incision site pain for up to six weeks post-operative, on average, and 86% (n=36) of recipients return to work within six months. The average time to return to regular bowel movements is 4 +/- 2 days and the average time of return to regular activity level is 27 +/- 13 days. Preliminary results suggest that using PROs post-operatively obtains clinically useful information on the patient experience of recovery. A patient brochure was produced to translate this information to patients preparing for kidney transplant. This information can also be used to improve patient-centred clinical care, as well as inform supporting research. Next steps are to continue recruitment and reduce variance through increased compliance.
    Caelie Stewart
    Medical Student | University of British Columbia
  • Improving the mental wellness of Aboriginal peoples is a goal of Interior Health. This is demonstrated through the development of the IH Aboriginal Mental Wellness Plan (AMWP). This plan sets a clear path to work towards that goal through improving access to Mental Health and Substance Use (MHSU) programs and services for Aboriginal peoples within the Interior of British Columbia (BC). It also addresses the other strategic priorities of advancing cultural competency and cultural safety; ensuring meaningful participation; and improving health equity for all Aboriginal peoples. The IH AMWP is based on the voice of Aboriginal peoples, families, communities, and those that work with them in the Interior of BC. As such, guiding principles for this AMWP are influenced firstly by Aboriginal worldviews which set the foundation for action. They embed a strong focus on patient, family and community centredness, concensus, equity, meaningful engagemenet, interconnectedness and impact. Through the review of available information, evidence based and/or promising practice literature, and the engagement of key stakeholders, five areas of focus that have emerged: 1. Develop and Enhance Family & Community Based Prevention, Promotion, Awareness & Self-care Supports 2. Participate in Meaningful Engagement 3. Build Trauma-Informed, Culturally Safe IH MHSU Services 4. Increase Equitable Access, Improve Transitions and Reduce Barriers 5. Apply a Continuous Quality Improvement Lens These areas of focus include actions we are taking as well as steps that are foundational to achieving meaningful change and transformation potentially benefiting many generations to come. In order to monitor our work towards achieving lasting long-term change, the AMWP includes desired outcomes to guide evaluation of its impact. Yearly progress reports and an evaluation of the AMWP is in place to ensure we are on track. This AMWP requires committed leadership with a willingness to implement evidence informed and promising practices for Aboriginal peoples as well as innovation through
    Judy Sturm
    Aboriginal Mental Wellness Director | Interior Health
  • Delirium is prevalent in patients who are hospitalized. In Fraser Health delirium prevalence is 32.5 % across acute medical units. Patients with delirium have a 10-33% risk of death while in hospital and they also have a higher risk of morbidity with longer lengths of stay, risk of falls, infections and decubitus ulcers. Best evidence shows that primary prevention of delirium with non-pharmacologic, multicomponent approaches targeted at high risk patients is the best management. Our aim is to screen 80% of high risk admitted patients from the Emergency Department (ED) for Delirium by September of 2019. Our change method started with raising awareness of delirium in the medical staff and clinical staff with posters in the ED and providing education sessions for nurses and physicians on delirium. Next steps included introduction of the Confusion Assessment Method (CAM) to both physicians and nursing staff, as best evidence supported CAM as a bedside delirium instrument that screened for the presence of four clinical features of delirium. Education for nursing staff on the use of the CAM was provided and regular audits of CAM scores on the Emergency Nursing Assessment was posted in the department. Baseline data on use of the CAM score was collected and data on ongoing use of the CAM score was recorded monthly and then weekly with real-time data posted in the ED. Our ED showed an improvement from a mean of 5% of high risk admitted patients screened for delirium to a mean of 75% by the end of the summer of 2019. Our next steps are to collect outcome data for the impact of screening on pre-admit and post-admit delirium for high risk admitted patients in the hospital. Challenges we have encountered are in real-time data collection in the busy chaotic environment of the Emergency Department.
    Donna Sue
    Emergency Physician | Fraser Health
  • Reducing waitlists is a key priority for BC, yet pressures on the health care system can make it challenging to maintain timely access to surgical procedures. Teams at BC Children's Hospital (BCCH), BC Women's Hospital (BCWH) and BC Cancer Vancouver Centre (BCC-VC) are working together to catch up and keep up with demand through improving operating room (OR) efficiencies and managing waitlists effectively. Moreover, processes are employed to enhance patient experience during their surgical journey. For example, BCWH has improved its procedural sedation service to allow patients to undergo low acuity procedures while under conscious sedation in a procedure room rather than an OR. BCCH and BCC-VC are implementing initiatives to streamline scheduling and enhance the patient experience by offering a single point of contact and notification to patients during their wait for surgery. Further, at BCCH, the OR booking and waitlist management process transitioned from physician offices to its internal booking team. To date, through the optimization of gynecology services at BCWH, capacity for other OR procedures has increased. Through the expansion of OR capacity at BCCH, dental waitlist is significantly reduced to only 1% of patients waiting longer than 26 weeks for surgery as of beginning of Aug, 2019. To ensure that patient experience improves, surgical programs will conduct evaluations, to spread learning and ultimately streamline the whole system. One key example of organizational collaboration is the standardization of data collection and reporting tools, which has led to enhanced analysis and decision-making. With innovation and less-resource intensive models of care, advancement are made while improving patient experience. Continuous improvements will not be successful without the collaboration of our staff, which include our leadership, physicians, nurses and point of care staff. The surgical teams will continue to standardize the approach to surgical care to enable better outcomes for patients.
    Crystal Sun
    Project Manager | Provincial Health Services Authority
    Tiana Low
    Business Analyst and Project Support | Provincial Health Services Authority
  • Health Authority Managers, Patient Care Coordinators, and Clinical Nurse Educators dedicate a substantial amount of time and resources to conduct audits within their acute care units. In addition, there is limited confidence in the validity of self-reported audit data. In September 2018, the Fraser Health Authority's Clinical Quality and Patient Safety portfolio created a centralized Audit and Assessment Team to provide audit support and resources for these frontline staff across the health authority. The team is comprised of a team leader, coordinators, and co-op students, who conduct the audits centrally at a reduced cost. They work with operational and clinical leaders to conduct audits and provide data and reports to sites and leadership groups with the goal of improving patient care. The implementation of a centralized audit team enables frontline staff to allocate additional time to direct patient-centered care. The current audits monitor: care and discharge planning, medication reconciliation, high-alert medication safety, and patient-reported safety concerns. Since audits are conducted by this independent centralized audit team, the risk of bias is reduced, as compared to self-audits. Moreover, when the assessments require the collection of information directly from patients and families, a conflict of interest can be avoided, as the audit interviewers are not involved in the care provided to the patients. Furthermore, the existence of the centralized audit team allows for consistent reporting of practice within units, and also provides effective comparisons between units and sites. Consequently, frontline staff can be fully informed of their unit's performance, while their time can be apportioned to more urgent issues pertaining to direct patient care. A centralized audit team allows for unbiased evaluations and consistent reporting of important patient safety and quality priorities.
    Shino Takizawa
    Coordinator | Fraser Health
  • BC Guidelines are evidence-based clinical practice guidelines produced by the Guidelines and Protocols Advisory Committee (GPAC), an advisory committee of the Medical Services Commission and a joint collaboration between Doctors of BC and the Ministry of Health. BC Guidelines are concise and user-friendly and are tailored to primary care context in BC by providing local content and resources. Over the past 20 years, GPAC has developed more than 60 BC Guidelines on a wide range of topics such as diabetes, asthma, heart disease and opioid use disorder. Our storyboard will highlight how BC Guidelines are developed, how GPAC collaborates with stakeholders across the BC health care system, and how stakeholders and practitioners can contribute to guideline development. We will report on guideline implementation and evaluation strategies (e.g., monitoring changes in lab test ordering and web analytics). We will also report on the impact of redesigning our external review process and adding an online survey to complement our traditional paper-based process of consulting with over 600 BC practitioners including family physicians, nurse practitioners and other key specialties and stakeholders. We will highlight recently released guidelines including Viral Hepatitis Testing, Vitamin D Testing, Chronic Kidney Disease in Adults, Appropriate Imaging for Common Situations in Primary and Emergency Care, Adverse Childhood Experiences, and Managing Pain.
    Katey Townsend
    Research Officer | Ministry of Health
    Fritha Munday
    Research Officer | Ministry of Health
  • Getting to Know ABBY - Enhancing Meaningful Activity For Staff and Patients On An Acute Tertiary Geriatric Psychiatry Unit with Innovative Technology ABBY is a wall mounted computerized unit that is designed by Ambient Activity Technologies for persons with dementia. It is based on Montessori principles, and includes interactive touch-screen monitors, sensors and programs with familiar, tactile and activity based experiences. These may include turning a wheel, flipping a switch or petting a cat. This interaction then accesses media content such as games, pictures, music and videos. It is hoped that the use of ABBY on our geriatric unit will contribute to improved quality of life for the person, enhance family/visitor experience, and improve staff satisfaction by enhancing their ability to easily provide fun activities. We purchased an ABBY unit for the inpatient geriatric psychiatry unit at Hillside Centre. Hillside Centre is a 47-bed acute tertiary mental health hospital that supports the Interior and Northern Health Authorities of British Columbia. It has a 12-bed geriatric psychiatry unit that provides an inter-professional team approach for those admitted to the service. As the first hospital in Canada to use ABBY, we developed a quality improvement project with several objectives in mind. We developed satisfaction surveys for patients, families and staff. Our project spanned 7 months, with a start date of December 1, 2018 and an end date of June 30, 2019. Our storyboard highlights information from this project period.
    Alicia Vicic
    Clinical Practice Educator | Interior Health
  • The current opioid crisis highlights the necessity to prioritize opioid stewardship, a modern concept described as "coordinated interventions to improve, monitor and evaluate the use of opioids to support and protect human health." In February 2018, Fraser Health approved funding for two pharmacists to implement a novel, organizational, hospital-based Opioid Stewardship Program (OSP); first of its kind in Canada. The program launched in Royal Columbian hospital in 2018, and in Surrey Memorial Hospital in 2019, with a framework to promote optimal, safe opioid prescribing in hospital and at discharge with the goal of avoiding opioid related adverse outcomes without compromising pain management. Successful implementation of the OSP requires strong executive sponsorship and shared ownership to foster cross-disciplinary collaboration. To leverage expertise of individuals with vested interest in opioid safety, an Opioid Stewardship Advisory Committee composed of administrative leaders, physicians, pharmacists and nurses was created in June 2019. The committee aims to support the OSP to implement strategies, and advise the direction, processes and actions of the OSP. Experience from American institutions implementing OSPs is gradually being published, and the most effective interventions to optimize opioid prescribing are unclear. The Fraser Health OSP is modelling successful antimicrobial stewardship programs where audit and feedback is a proven intervention. The OSPs pharmacists initiated prospective case reviews with consult service and screening of patients to provide real-time clinical support. To influence opioid prescribing systemically, the OSP was added to the Fraser Health Quality Assurance Team, which reviews all new pre-printed orders to make hospital-specific and regional recommendations. The OSP also seeks to enhance knowledge translation on opioid prescribing for clinicians and patients, and implement system improvements to improve prescribing surveillance and patient monitoring. Sharing successes and challenges in coordinating system-wide OSP strategies may assist institutions to build on our approaches to optimize opioid prescribing.
    Sharon Vipler
    Program Medical Director & Regional Department Head, Addiction Medicine | Fraser Health
  • Background The social determinants of health (SDOH) account for up to 55% of health outcomes, however systemic and structural changes are slow and may not impact individuals who are currently living with unmet social needs. Primary care is one area that is critical in mediating individual social needs as it is a natural point of integration between clinical care, public health, behavioural health, and community-based services. Currently, screening for and addressing the social needs of patients is difficult for various reasons, including time constraints, varying eligibility criteria, and inadequate information about local resources to follow-up on identified concerns. Intervention Basics for Health Society (B4H) and the Health Connection Clinic have partnered to develop a web-based government assistance navigation tool for the primary health care team. The tool will consist of a series of screening binary questions which a team member can answer with patients to determine eligibility for various British Columbian and/or Canadian government assistance programs. The tool is intended to be completed during a primary care visit and the information can become part of the clinic visit, patient record, and patient action plan, while also informing the team of next steps and resources. The tool will be piloted at two primary care clinics in fall 2019 and an evaluation will inform subsequent versions. Impact The goal of the tool is to provide a solution to the barriers that hinder the primary care team from addressing individual social needs, focusing on individuals who require income support. The tool is an important first step in providing a solution for the barriers that Canadian primary care teams face, and will contribute to a more holistic and informative primary care visit inclusive of social needs. The tool can be adapted and used by professionals working with vulnerable people in other settings.
    Melissa Wan
    Board Member | Basics for Health Society
    Charlotte Humphries
    Interim Executive Director/ Staff | Other (please specify)
    Sarah Kesselring
    Board Member | Basics for Health Society
  • Canada's culturally diverse population (CDP) experience difficulties such as language barriers, difficulty navigating the healthcare system, and lack of culturally tailored resources, compared to the general population when accessing mental health services. Technology can improve quality to underserved populations through e­-mental health which involves services and information delivered through the Internet and related technologies. However, this approach is currently limited and must be culturally tailored for optimal effectiveness. This study aims to investigate the use of e­-mental health among CDP for anxiety and depressive disorders in the Metro Vancouver Regional District. Our objectives are: (1) To explore the experience of digital mental health services and assess its efficacy with CDP, (2) To identify connections between ethnicity, digital health literacy, and experiences of mental health difficulties, and (3) To make recommendations for the development of e­-mental health services for culturally diverse populations. Participants will fill a survey involving questions around e­-mental health use, the severity of their depression and anxiety symptoms, and socio­demographic characteristics. Participants will be invited to a focus group to share their experiences with e­-mental health and provide recommendations for improvement. We aim to have over 200 filled­-surveys and four to eight participants for three focus groups. This project will benefit CDP in Canada by improving access to effective treatments for anxiety and depressive disorders using technology, providing health care professionals with a greater understanding of treatment needs in ethnic minority groups, and supporting the development of culturally relevant e­-mental health resources and services for CDP.
    Shawna Narayan
    Researcher | University of British Columbia
  • Physician-led Quality Improvement (PLQI) is a Specialist Services Committee (SSC) initiative under Vancouver Coastal Health (VCH) and Providence Health Care (PHC) funded by Doctors of BC and Ministry of Health to address gaps in quality structures relating to physicians participating in quality improvement (QI) activities, building QI expertise and leadership skills to lead QI projects. This investment increases physician involvement in QI and enhances delivery of quality patient care and outcomes. Relevance: This year's proposals has substantially increased and exceeded our funding capability. With increased interest to apply a QI lens to projects, only 33% were successful to receive funding, 15% were waitlisted pending funding to be identified, and 52% were unsuccessful. Intervention: 1. To better support funded projects, PLQI collaborated with PHC and Team Based Quality Improvement (TBQI) to connect physicians to existing clinical quality teams. 2. To not lose momentum and interest of these engaged physicians, PLQI explored and identified other opportunities and funding sources from VCH/PHC and Facility Engagement (FE). Also they were invited to 1-day QI training and IHI Open School to further enhance their QI knowledge and skills. 3. Unsuccessful applicants were redirected and connected to Operations Leaders in various departments to explore potential support. Potential/Actual Impact: To ensure project success, potential sustainability and spread, 57% (13/23) physicians have started collaborations. 30% (3/10) of waitlisted physicians are being funded through FE. 88% (21/24) unsuccessful physicians were redirected to other departments. Originality: Recognizing the importance of collaborations with existing QI structures and departments, even unsuccessful physician applicants were connected to Operations enabling all physicians who are engaged and motivated to continue on the QI journey. These collaborations between projects, structures and departments will only help strengthen the QI culture.
    Hing Yi Wong
    Program Advisor | Vancouver Coastal Health
    Amy Chang
    Program Advisor | Vancouver Coastal Health
  • Background: Delirium has been shown to affect approximately 30% of acute medical inpatients, resulting in longer length of hospital stay and earlier admission to nursing homes. As part of the larger regional goal to improve delirium care in Fraser Health Authority, we wanted to investigate the use of anti-psychotics and anti-cholinergics. Objective: To minimize the morbidity associated with anti-psychotics and anti-cholinergics in Fraser Health patients with delirium by 2019. Methods: A medical chart audit tool was developed. Every other month from January 2017 to May 2018, 10 charts were randomly selected from coded data in Chilliwack General Hospital (CGH), Eagle Ridge Hospital (ERH), Royal Columbian Hospital (RCH), and Surrey Memorial Hospital (SMH). Outcomes measured included: pre-admission, admission, and post-admission prescriptions with regards to anti-psychotics and anti-cholinergics, as well as discharge disposition. The previously validated Anti-cholinergic Cognitive Burden Score (ACB) was adopted to compare individual potencies of anti-cholinergic agents. Qualitative analyses with descriptive and inferential statistics were used to analyze the data.  Results: A total of 358 charts were reviewed. For patients on anti-psychotics, 29 were admitted while 65 were discharged on 1 or more agent. For patients with an ACB score > 0, 56 were admitted while 87 were discharged. 185 patients had an ACB > 0 during admission. In all sampled patients throughout their journeys pre-admission, during admission and post-admission, 1236 ACB scores were calculated and 591 were attributable to quetiapine (ACB = 3 = high). Conclusions: Despite efforts to focus on non-pharmacologic care, patients were still discharged with more anti-psychotic and anti-cholinergic medications compared to prior to admission. Higher ACB scores during admission were associated with less independence on discharge (i.e. transfer, residential care, or death). For future focus, the most common agent with high anti-cholinergic properties prescribed was quetiapine.
    Jennifer Wong
    Primary Investigator | Fraser Health
    Jean Warneboldt
    Investigator | Fraser Health
  • Using System Data to Reduce Unnecessary Routine Bloodwork // Is data a friend or foe for quality improvement projects? Although health administrative data has the potential to provide new insights and trends, often times the data needed to drive quality improvement (QI) work is either not readily available, difficult to access, and lacking clinically relevant information. This presentation illustrates a project in which we used an iterative approach of analyzing administrative data to address unnecessary routine bloodwork in the clinical teaching units (CTUs) of a tertiary care centre. Rather than reviewing individual patient charts which would be impracticable, we sought to explore QI opportunities by using data from our lab and administrative databases to identify objective trends and patterns in a comprehensive scope. In our first data analysis attempt, we extracted information on CTU patients with daily blood collections, collections with abnormal results, and consecutive collections with normal results. However, the aggregated data was unable to establish any meaningful patterns of over-ordering as there were no benchmarks. The project was recently re-visited when a chart review revealed many of our routine bloodwork could be avoided. With this observation, a multidisciplinary team was formed and examined the percentage of patients with daily routine bloodwork versus their length of stay. We were able to demonstrate that patients were having daily bloodwork throughout their hospital admission, with no reduction closer to discharge. We would like to share our learnings and highlight the importance of having a hybrid approach, using small-scale audits interpreted by multidisciplinary content experts to analyze large data sets to find trends and patterns amenable to QI initiatives. We will also discuss the pros and cons of using aggregated administrative data vs. chart reviews for QI projects; and advocate instances where a hybrid approach is needed.
    Sophia Wong
    Medical Biochemist | Vancouver Coastal Health
    Andrew Shih
    Hematopathologist | Vancouver Coastal Health
  • Context: The UBC Pharmacists clinic (the clinic) implemented a learning activity for student pharmacists and post-graduate residents (learners) on practicum using audio-video equipment in a primary care setting. With patient consent, learners conducting a live, in-person 60-minute patient consultation were recorded for real time observation from the preceptor and for learner reflection and self-assessment at a later time. The goal was to determine areas of skill development learners found were positively impacted by this activity within a pharmacist-led primary care clinic. Intervention: During the recorded consultation, the preceptor observed and assessed the learner's performance via a monitor. The learner assessed their patient care skills prior to and immediately following watching their consultation. Both the preceptor and learner utilized a standardized assessment form and discussed the learner's performance. From Sept 2018 to July 2019, learners completing a 4 or 8 week practicum at the clinic were invited to participate in the assessment of this learning activity. An online feedback survey was placed on Qualtrics Survey tool and responses were anonymized. Measurement: Likert-style statement results were summarized as averages and standard deviation and open-ended responses were analyzed from a total of 8 participants. Learners identified four key areas of patient consultation and communication skills that were positively impacted which include appropriate questioning, clear and concise language, time management and non-verbal habits. The learners' level of agreement that reviewing a video recording of their own patient encounter was beneficial to the development of their patient consultation skills scored an average of 4.13/5. Lessons: A learning activity recording patient consultations for pharmacy learner review and self-assessment was helpful in the areas of appropriate questioning, clear and concise language, time management and non-verbal habits. This approach is sustainable in a clinic setting equipped with audio-video technology and can be applied to other healthcare educational settings.
    Jamie Yuen
    Clinical Pharmacist & Lecturer | University of British Columbia
  • Context & Relevance: Lung cancer is the leading cause of cancer-related death in British Columbia. Molecular-biomarker screening for advanced non-small cell lung cancer (NSCLC) patients identifies prognostic and predictive targetable mutations and diversifies systemic treatment options, resulting in improved survival outcomes and enhanced quality of life. Oncopanel testing is a multi-gene analysis panel providing information on molecular-biomarker targets to help direct a more personalized approach to treatment for patients with advanced lung cancer. Oncopanel testing requires the involvement and coordination of four separate departments (physician's office, host hospital pathology lab, BC Cancer pathology lab, and Cancer Genetics Laboratory) and healthcare providers have noted the current provincial turnaround time for molecular-biomarker testing frequently exceeds the proposed international guidelines of 14 calendar days (International Association for the Study of Lung Cancer). Intervention /Methods: The differential and unpredictable nature of turnaround times delays definitive treatment discussions and leads to multiple patient re-booking events in anticipation of timing of results. This quality improvement project is a multi-phase process which will initially involve a retrospective chart review and process flow mapping to understand current diagnostic turnaround times related to molecular-biomarker testing requests at BC Cancer - Vancouver Centre. This step will be followed by quantitative analysis and interviews with interdisciplinary stakeholders and teams to identify strategic, measureable areas for process improvements and key change ideas within the system. These will be tested using plan-do-study-act (PDSA) cycles to provide informed solutions generation and long-term sustainability of the provincial molecular-biomarker testing procedure for non-small cell lung cancer patients. Potential Impact: This proposed quality improvement/assurance project has the goal to improve turnaround times for molecular-biomarker requests within British Columbia. We propose to do so by effectively and transparently communicating receipt of a request, easily accessing avenues to elicit the transit and reporting
    Kelly Zibrik
    Nurse Coordinator | Provincial Health Services Authority
    Ying Wang
    Medical Oncologist | Provincial Health Services Authority
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