OUR SHAREDPURPOSE

July/August 2019

Learning from patients How care

is being improved through patients’

feedback. (pg. 3)

“Getting back to myself”How a St. Michael’s clinic is helping

patients with back pain. (pg. 2)

Expanding care where patients live New off-site St. Michael’s dialysis centre to open in 2020. (pg. 8)

Hospitals learning together St. Joseph’s role in the Joint Centres for Transformative Healthcare Innovation. (pg. 7)

What it takes toinnovate (pg. 4)

Bridging another gap in our systemBringing peritoneal dialysis care to Providence addresses a pressing need. (pg. 4)

OUR SHARED PURPOSE2 OUR SHARED PURPOSE 3

Neng Li was playing ice hockey with his two young children when

he suddenly felt a pain in his lower back. On the advice of his wife,

he visited his family doctor, who provided him with a referral for a new

St. Michael’s clinic that would help get him back on his feet.

Opened earlier this year, the Rapid Access Clinic (RAC) for Low

Back Pain is one of three sites across the city designed to help improve

the speed, access and quality of care for people with low back pain.

Within four weeks of a referral, patients are scheduled for a

consultation. At the consult, they receive a standardized assessment

and self-management strategies, or a referral for a surgical or other

specialist consult.

The system, says Dr. Andrew Bigness, practice lead at the

St. Michael’s clinic, is intended to help patients self-manage their

back pain and reduce unnecessary diagnostic imaging and specialist

referrals.

“Eighty per cent of people will experience back pain in their

lifetime,” said Dr. Bigness, who also works as the clinic’s advanced

practice practitioner. “If people learn to manage their pain on their own,

it lessens the burden on the system by reducing wait times for surgical

consults and MRIs. ”So far, only 15 per cent of the clinic’s patients have

needed a surgical assessment, and even fewer have required surgery.“

But when they do, Dr. Henry Ahn, the clinic’s surgical lead, is ready

to step in. An orthopedic surgeon at St. Michael’s Hospital, Dr. Ahn

meets with patients who’ve been pre-screened by Dr. Bigness and

deemed a possible candidate for surgery, like Li.

“I don’t see every patient, which is the goal in order to reduce clinic

load,” said Dr. Ahn. “I only see patients who need surgery, so I can focus

on the area that I can serve best.”

Working with Dr. Bigness, Dr. Ahn said he hopes to recruit and train

more assessors to work in the clinic, allowing them to continue to help

other patients like Li. Two months after his injury, Li said he’s feeling

better every day.

“Thanks to the clinic, I’ve been able to get back to my old self,” said

Li. “My kids are always asking me to play hockey or basketball outside

and it’s nice to be able to say yes again.”

Our Shared Purpose is a monthly newsletter highlighting our people and the ways they are improving care, patient experience and the health of our communities.

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Registered nurses Katherine Mansfield and Sarah Kreher never

would’ve thought that bedside whiteboards could dramatically

affect the care experience until they heard it directly from

patients.

Research suggests that low health literacy is associated with

lower adherence to medication, poor chronic disease management,

and increased hospitalization.

In response, the Patient and Family Education program at Unity

Health Toronto created workshops and courses that help staff,

physicians, and learners develop more impactful patient education

strategies and resources.

“Many patients have difficulty understanding or remembering

information provided by health care providers. We’re trying to bridge

these gaps,” said Katrina Grieve, a patient education specialist in

St. Michael’s Patient and Family Education program.

Community of Practice sessions provide a forum to hear directly

from patients and families and share ideas. Kreher, Mansfield and

clinical leader manager Joanne Bennett say patient voices have left a

lasting impression on their work.

On St. Michael’s general surgery unit, each bed has a whiteboard

that should be – but isn’t always – updated daily with information like

how the patient is feeling, what they prefer to be called, and names

of their care team members. Bennett and Mansfield were surprised

to hear that patients feel demoralized when staff don’t take time to

update the whiteboards. “One patient told me he ‘feels like he matters’

when clinicians incorporate information from the board into his plan of

care,” said Bennett.

In St. Joseph’s renal outpatient clinic, dietitian Fiona Bellefeuille

cares for patients who live with chronic illness. She recently attended

a session on developing patient videos to help people with disease

management. “Our clinic patients on hemodialysis sit in chairs for

four hours and each chair has a TV,” said Bellefeuille. “Simple, visual

materials are so effective and transcend barriers.”

For Valerie McWhinnie, a physiotherapist at Providence, one of

her most valuable learnings was about the teach-back technique – an

approach to teach or present complex information by breaking it down

into simple pieces and having patients repeat in their own words what

they just learned.

“I now ask patients ‘can you tell me what you understand?’ You

may think you’ve given great information but you don’t always know

what they’ve absorbed,” said McWhinnie.

Neng Li says he’s “back to my old self” thanks to the Rapid Access Clinic (RAC) for Low Back Pain. (Photo: Yuri Markarov) Nurses Honeylet Rivera (left) and Ranjeeta Rungta (right) discuss what to add to a patient’s whiteboard.(Photo: Katie Cooper)

by Emily Dawson

Listening to patients

New clinic at St. Michael’s is

improving the quality of care

for people with low back pain

by Anna Wasserman

Getting back on your feet

Reimagining patient education

by building better tools to

improve health literacy

OUR SHARED PURPOSE4 OUR SHARED PURPOSE 5

Providence in April. Mark requires 10 hours of PD each night, and his

nurses are responsible for beginning the process every night and ending

it each morning. On-the-job refreshers supplement the training they

received from Benjamin-Wong.

“Patients on PD will watch their care team like a hawk, because PD

is their lifeline. They become the teachers. So while I’ve been able to train

staff to get the service up-and-running, their ongoing learning comes

from patients themselves,” said Benjamin-Wong.

Seizing this opportunity helps position Unity Health Toronto as a

leader in bridging gaps across our system. By bringing the right care

to the right setting, we’re ensuring that everyone can access the

treatments they need to thrive.

Over time, Providence hopes to extend its new PD expertise to

other programs, such as Palliative Care and the Cardinal Ambrozic

Houses of Providence long-term care home, to benefit even more

patients with PD needs.

Mark’s rehab is progressing nicely and he believes he’ll be back to

work in some capacity soon.

“On the day I arrived, I met the physio and occupational therapists

and the physician. Right away, they wanted to know what my recovery

goals were. For me, it was simple: to walk down the hall at Providence

with my walker. I knew if I could do that, I’d be well on my way,” said Mark.

“Shortly into rehab, though, I realized that was not going to happen

in the near future. I’ve come to grips with this setback. So for now, I’m

working on being totally comfortable and mobile in a wheelchair. If I can

accomplish this, we’ll start working on my long-term goals.

“I’m still gaining strength in my legs, arms and core but I’m getting

there. I don’t know what I would have done without the rehab at

Providence. The care has been marvelous.”

Clockwise from top left: The team in St. Michael’s Home Dialysis/Kidney Care Centre; the Providence team on A5; staff get the PD cycler ready for the next treatment; Ray Mark and Fatima Benjamin-Wong share a laugh in his room at Providence.(Photo: Katie Cooper)

St. Michael’s and Providence work together

to expand peritoneal dialysis care.

by Emily Dawson

Collaborating for better care

Across Toronto, few rehab facilities have staff trained to provide

peritoneal dialysis. That could’ve been an issue for Ray Mark.

Mark knew he’d need extensive rehabilitation following a series of

significant health issues last winter that left him unable to use both of

his legs. Mark had lived a full and busy life. He was working at a job he

enjoyed, loved spending time with his young granddaughter and had

an active social life with his partner, Nettie.

But last November, everything suddenly changed.

When he experienced some unusual shortness of breath, Mark

made the drive from Ajax to St. Michael’s to have it checked out. A few

weeks later, he woke up from a coma in the Intensive Care Unit, with

barely a memory of what had happened.

“I remember sitting in the waiting room in emerg and hearing my

name called,” said Mark. “I learned later that I’d had two heart attacks,

and then a mini-stroke in the coma.”

During his five months at St. Michael’s, he stabilized and received

the medical care he needed, including peritoneal dialysis for his kidney

disease. Peritoneal dialysis, sometimes called PD, uses the lining of the

abdomen and a cleaning solution called dialysate to clean the blood. It’s

usually self-managed by patients as part of a home-dialysis treatment

plan but was provided by his care team at St. Michael’s.

Fortunately for Mark, before he would be transferred to Providence

for rehab, a new Unity Health Toronto initiative meant he could continue

to receive peritoneal dialysis there.

Identifying the need for better integrated care for our communities,

the new initiative saw Fatima Benjamin-Wong, a home dialysis case

manager from St. Michael’s, train 30 Providence staff with the goal of

being able to admit rehab-eligible patients needing peritoneal dialysis.

“It was a pleasure working with Providence’s A5 team, led by patient

care manager Sofia da Silva,” said Benjamin-Wong. “I’m so impressed

with how staff have embraced this learning opportunity, wanting to

understand the holistic view of the renal patient and gaining confidence

in providing PD.”

The team on A5 was ready when Mark was transferred to

OUR SHARED PURPOSE6 OUR SHARED PURPOSE 7

SHARING MEDICAL IMAGING DATA TO CUT RADIATION DOSESPatients might expect radiation doses for CT scans to be comparable from one hospital to the next, but a team at St. Michael’s Hospital says the dose variance can be startling. The team is collecting and analyzing data from eight hospitals for the Medical Imaging Metadata Repository of Ontario (MIMRO) to help reduce the province’s average radiation dose per scan. Using artificial intelligence to sort the hospitals’ data, the team generated comparative data by facility, scanner and exam to help determine best practices. MIMRO is funded primarily by St. Michael’s and was created by two of its radiologists, Drs. Timothy Dowdell and Bruce Gray.

Radiologist Dr. Bruce Gray and data analyst Lianne Concepcion review data submitted to MIMRO. (Photo: Katie Cooper)

OPPORTUNITIES TO IMPROVE ESSENTIAL MEDICINES LISTSCountries’ essential medicines lists vary greatly from one another and from the WHO’s model list, pointing to a potential need for greater care in selecting medicines that best meet the health-care priorities of a population, suggests a study led by Dr. Nav Persaud, a scientist at the MAP Centre for Urban Health Solutions. The research was recently published in the World Health Organization Bulletin. “Countries must select medicines for their lists appropriately, in order to facilitate sustainable, equitable access to medicines, and to promote their appropriate use,” said Dr. Persaud. “Differences between lists that are not explained by country characteristics may represent opportunities for improvement

St. Joseph’s is part of the Joint Centres for Transformative

Healthcare Innovation, a group of seven hospitals across the

city who work together on making care better and safer for

patients. They do this in several ways: they share best practices with

one another, allowing other teams to build on great work that’s already

shown to be successful; they collaborate on initiatives that impact all

hospitals such as workplace violence and medication safety; and they

bring teams together to learn with and about one another to build

connections and increase knowledge at all hospitals. Here’s a quick

snapshot of what you need to know about this important work.

Who else belongs to the Joint Centres for Transformative

Healthcare Innovation?

The six other hospitals who belong to the Joint Centres with

St. Joseph’s are: Humber River Hospital, Mackenzie Health, Markham

Stouffville Hospital, Michael Garron Hospital, North York General

Hospital and Southlake Regional Health Centre.

What is InnovationEx?

InnovationEx is the Joint Centres’ biggest annual event where teams

from the seven hospitals come together to learn with and about one

another. The event includes guest speakers as well as a poster fair –

each hospital shares some of the exciting work they have on the go

and members of the team are available to answer questions and talk

about how they could help bring their initiative to partner hospitals.

This year, St. Joseph’s teams shared information about the patient-

oriented discharge summary project that gives easier-to-understand

information to patients at discharge so they’re better able to manage

at home. They also shared the Emergency Department (ED) reduction

project where the ED has partnered with community resources to help

reduce repeat visits.

What else has the Joint Centres collaborated on?

The Joint Centres hospitals have also worked together on:

• preventing workplace violence

• reducing C-section rates

• spreading Choosing Wisely initiatives to reduce the number of

unnecessary tests and treatments patients experience

• reducing C. difficile infections for inpatients

To help doctors make better decisions about which kidneys to accept for transplantation, a research team at St. Michael’s is testing a first-of-its kind kidney-imagining technique in clinics. In collaboration with Ryerson University through the Institute for Biomedical, Engineering and Technology (iBEST), the team aims to perfect ultrasound-based methods that measure scarring in transplant kidneys. Kidney failure is a growing problem in Canada, and with few kidneys available for transplantation, doctors have begun to accept kidneys from sicker donors. While some perform well, others are not as effective. “We currently have no way of assessing donor kidneys,” said Dr. Darren Yuen, a scientist in the Keenan Research Centre for Biomedical Science. “Our study has the potential to revolutionize how we allocate kidneys for transplantation.”

REVOLUTIONIZING OPTIONS FOR KIDNEY TRANSPLANT

An average of at least one potential concussive event occurred per game during the 2016 UEFA European Championship and most incidents did not result in a medical assessment by a sideline health-care personnel, according to research published in the journal BMJ Open. The research shows there’s a need to mandate the proper assessment and management of players suspected of concussion, said Dr. Michael Cusimano, neurosurgeon and scientist at the Li Ka Shing Knowledge Institute, who led the research. “It’s imperative that the highest levels of the sport assess potentially concussed athletes appropriately,” said Dr. Cusimano. “Given the ‘trickle-down’ effect from professional levels, the health of players at all levels demand that groups like FIFA and UEFA follow the protocols to which they were a signatory.”

CONCUSSION ASSESSMENT IN SOCCER NOT UP TO EXPERT RECOMMENDATIONS

Health care professionals share best

practices at annual event

by Amber Daugherty

Learning and improving together

St. Joseph’s shared new initiatives with hospital partners at this year’s InnovationEx event

KRCBS scientist Dr. Darren Yuen is collaborating with Ryerson University’s Dr. Michael Kolios on an innovation for transplant. (Photo: Medical Media)

Dr. Nav Persaud, a scientist at the MAP Centre for Urban Health Solutions, led a study examining essential medicines lists across 137 countries. (Photo: Medical Media)

OUR SHARED PURPOSE8

Dialysis patients of St. Michael’s will soon have the option to

dialyze in one of two neighbourhoods in Toronto.

Next year, a brand new 20,000-square-foot dialysis centre will be

opening in the East York Town Centre in Thorncliffe Park, expanding

St. Michael’s dialysis services that are currently only offered inside the

hospital.

The new St. Michael’s Kidney Care Centre, presently undergoing

the first phase of construction, will offer 21 dialysis stations for patients,

with an additional six for home hemodialysis training, transition and

support.

“The value of this satellite centre is that it meets the needs of

patients in their own community,” explained Alison Thomas, a nurse

practitioner in St. Michael’s hemodialysis unit.

“It also allows us flexibility with new patients. We’re now able

to offer them an alternative location for their care, away from the

downtown core.”

The space for the multidisciplinary care centre was selected

specifically due to its central and convenient location in a

neighbourhood that has underserviced dialysis needs, its free parking

and TTC access, and its accessible location on the ground floor.

“I think it’s important that we don’t always bring dialysis patients

to the hospital for their treatment,” said Elizabeth Anne Anderson,

the clinical leader manager for the Multicare Kidney Clinic, Home and

Satellite Dialysis Clinics at St. Michael’s, and one of the team members

who chose the location of the satellite clinic.

“Dialysis is a life sustaining therapy that often does not need to

be provided in an acute hospital setting. We’re hoping that going to

an offsite satellite clinic for their treatments will allow patients to view

dialysis as a way to maintain wellness, rather than to treat illness.”

St. Michael’s dialysis patients who choose to dialyze in the new

satellite clinic will remain connected to their St. Michael’s team. There

will be no transfer of care if they choose to dialyze outside of the main

hospital site.

“We look forward to providing dialysis care in the community in

a centre that has been designed with patients, family members, and

caregivers in mind,” said Anderson.

Construction begins on St. Michael’s

satellite dialysis clinic in Thorncliffe Park.

by Selma Al-Samarrai

Improved accessfor dialysis patients

Alison Thomas, a nurse practitioner in the St. Michael’s hemodialysis unit, is pictured here

speaking to hemodialysis patient Paulette Caine. (Photo: Yuri Markarov)