Medical Quality Leadership & Practice2018 ANNUAL REPORT

We believe that medical staff are vital for delivering exceptional care. We support them by enhancing their capacity and capability to lead continuous improvements in practice and quality.

This purpose of this report is to showcase the work of the Medical Quality Leadership & Practice department as situated within the overall quality agenda for VCH & PHC. We strive to continue to form new partnerships with medical staff, promote a continuous quality improvement culture and support the delivery of quality medical care. This report showcases our work by program area, to highlight the impact that this work has had on medical staff & patients.

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We believe that Medical Staff are vital for delivering exceptional care. We support them by enhancing their

capacity and capability to lead continuous improvements in practice and quality.

Medical Quality Leadership & Practice

An individual level snapshot of practice metrics showing peer comparison and year to year comparison to facilitate

physician understanding of their medical practice and support professional development.

Medical Quality Council-derived online survey to support physicians’ understanding and demonstration of medical practice competencies as per the CanMEDs framework.

Supporting the professional growth of our leaders to ensure clinical quality.

In-depth self-assessment and perspectives from medical colleagues and co-workers.

Provides physicians with understanding of their practice to support learning and quality improvement.

Facilitated feedback with a trained reviewer to review feedback and create goal-oriented learning plan.

Solutions range from education and point of care interventions, to influencing policy and system

wide practice.

To promote physician-patient conversations & help patients choose care that is free from harm, truly necessary and

supported by evidence.

Advocating on behalf of medical staff, we work collaboratively with internal and external groups to

highlight the unique perspectives of medical staff, and where possible, shape their organizational interactions.

To strengthen the quality improvement capacity and culture within our physician community.

Determined by the medical departments, measures includes metrics that are clinically relevant and patient

reported outcome measurements (PROMs).

ACCREDITED QI TRAINING

SESSIONAL FUNDING FOR QI PROJECTSMEASURES

360 ASSESSMENTASSESSMENT & FEEDBACK

ONE-ON-ONE

MEDICAL LEADERSHIP ASSESSMENT

INTERNAL TRAINING

PROGRAMS

RESOURCE CENTRE

MULTI-SOLUTIONS

COLLABORATIVE PARTNERSHIPS

ANONYMITY

QI ADVISORS FOR COACHING & ORGANIZATIONAL

NAVIGATION

TECH SUPPORT INCLUDING DATA

ANALYSIS

Data can only be reviewed by individual physicians, their site heads and regional department heads.

Physician Practice Enhancement (PPE)

Physician Multi-Source Feedback (MSF)

Medical Leadership

Appropriateness Review/Choosing Wisely

Medical Staff Experience

Physician Led Quality Improvement (PLQI)

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Physician Practice Enhancement (PPE) 1

An individual-level snapshot of practice metrics showing peer comparison and year to year comparison to facilitate physician understanding of their medical practice and support professional development and quality improvement.

Practice reports include clinically relevant measures that are chosen by the medical departments as well as

patient reported outcome measurements (PROMs). Data can only be reviewed by individual physicians, their

site heads and regional department heads. Dashboards of practice metrics are available to view in Tableau.

VCH/PH departments who have adopted the PPE program include: Internal Medicine, Emergency

Medicine, Radiology, Obstetrics/Gynecology, Pediatrics, Anesthesiology, Psychiatry, Orthopedic

Surgery, Ophthalmology, and Urology. Our current priority is to launch the program with Primary Care

and with Medicine in 2019.

60% to 80%

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Impacts of Our Work

The Department of Obstetrics and Gynaecology began building a PPE Program at a single site 10 years ago.

This program has now expanded to the whole region and the impact of this work includes:

The PPE report provides professional development plans. The Physician Quality Assessment & Improvement Team has helped us to develop performance indicators that are meaningful to our department members, as well as easier ways to visualize performance longitudinally and compare oneself to peers. They are excellent partners in Quality Assurance.

Physician quality team is incredibly responsive, helpful, and supportive in working with us to facilitate the development and implementation of PPE metrics for psychiatry; the data are certainly making us to rethink about prescribing behaviour and their potential impact on clinical outcomes.

REGIONAL DEPARTMENT HEAD,

OBSTETRICS AND GYNAECOLOGY

Dr. Lakshmi Yatham REGIONAL DEPARTMENT HEAD,

PSYCHIATRY

An improvement in the

median rates of minimally

invasive hysterectomy surgery

at VCH, PHC & PHSA from

A rise in the mean of VBAC

successful rates at BCW from

A drop in the mean of

maternal complication at

BCW from

61% to 73% 12% to 9%

The Regional Perinatal Coordinating Council is developing a quality improvement project around improving

vaginal birth rate. The project will be cross disciplines and specialities – involving perinatal staff, midwifery,

family practitioners, and obstetricians across VCH and PHC.

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Physician Multi-Source Feedback (MSF)

Medical Quality Council-derived online survey to support physicians understanding of and demonstration of medical practice competencies as per the CanMEDS framework. Rather than a quality assurance initiative, the goal is the development of personal insight and self-awareness for the purpose of practice improvement.

Components: An-depth self-assessment

and perspectives from medical

colleagues and co-workers every 3–5

years; One-on-One facilitated feedback

with a trained reviewer to review

feedback and encourage the creation of

a goal-oriented learning plan.

Metrics

The MSF Process

Self-Survey (Participant)

Feedback from Contributors

Share Results Report

Facilitated Feedback Session

with Reviewer

Create Learning /Development Plan

MEDICAL EXPERT

Scholar

Collaborator

Leader

Health Advocate

Professional

Communicator

Medicine, Surgery, ED, Psychiatry,

Obs / Gyn, Ophthalmology, Radiology

have completed their

MSF survey.

have completed the Coaching

workshop & are primed to

hold facilitated feedback

sessions with staff & support

the creation of action plans.

7 Departments on board: 100 Physicians40 Medical Leaders

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We are collaborating with the Medical Council of

Canada and will incorporate their updates to the

questionnaires used, based on their substantial

review and updates.https://mcc.ca/assessments/mcc360

Next Steps

I have found the process to be personally useful and

it has been fun guiding others through it. I think it is

a valuable exercise to complete every few years. I

think the process encourages introspection into

ones own strengths and weaknesses, then in a safe

way it reaches out to others for similar feedback.

It facilitates a dialogue on those strengths and

weakness and highlights areas for growth.

The facilitated feedback process helped me to

review the feedback, interpret it and move forward

with possible positive steps for self-improvement that

I may not have otherwise considered.

What was more helpful than the actual rating scales

were some of the narrative feedback. They got a lot

of useful information from their feedback and they

found it quite helpful. I thought it was awesome and

I’d do it again in a minute.

The facilitated feedback process helped me to reflect

on broader issues of leadership from someone who

has had substantial experience in this area.

Dr. Stephanie Wise MEMBER, OPHTHALMOLOGY DEPARTMENT

Physician Participant

Dr. Gradon Meneilly REGIONAL DEPARTMENT HEAD, MEDICINE

Physician Participant

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Appropriateness Review / Choosing Wisely

To promote conversations between physicians and patients by helping patients choose care that is free from harm, truly necessary and supported by evidence.

Components: Provides physicians with an

understanding of their practice to support learning

and quality improvement; solutions range from

education and point of care interventions, to

influencing policy and system wide practice.

Impact of Our Work

Decrease in average percentage of MRI for major joints of outpatients at VA (>=55yrs)

Of all MRI cases protocoled; of cases were avoided (129 of 623)

Decrease in median proportion of uncomplicated headache patients that received an imaging order from LGH ED

Decrease in the percentage of head CT scans for outpatients at LGH

Low Back Pain

Osteoarthritis (>= 55Yrs)

ED

Community

17%

32.6%

22%

21%

33.3%

56%

644.3%

4.9%

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31Decrease in average percentage of CT arthrogram for major joints of outpatients at VA (>= 55 yrs)

9.2%

7.6%

a. Accomplishments of our pilot projects over the past 5 years:

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Uncomplicated Headaches

Building on the success of Choosing Wisely Medical

Imaging projects, the team has shifted the focus onto

the laboratory tests. The current project is working

on the single unit transfusion and daily bloodwork.

Work has started to explore opportunities to improve

appropriateness in care around CST.

CT, MRI and X-rays for uncomplicated back pain do not help you get better faster and may expose you to unnecessary risks.

Decrease in median proportion of low back pain patients that received an imaging order at SPH ED

In the absence of red flag symptoms, there is no evidence for the utility of advanced imaging in patients with significant osteoarthritis (OA).

Vancouver Acute Blood TransfusionWhy use two when one will do?

Increase in percentage of single red blood cell transfusion of medical patients

A new process designed for both emergency department and family practitioners for ordering of head CT for uncomplicated headaches.

%

%

%

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c. Knowledge dissemination:

Drs. Bruce Forster, Vivian Chan, Jonathan Leipsic DEPARTMENT OF RADIOLOGY GRAND ROUNDS, NOV 2018

b. From seed to sprout:

These seedling projects have sprouted: the Choosing Wisely appropriateness checklists for MRI requisitions

of lumbar & spine and hip & knee have been rolled out as part of the Lower Mainland Medical Imaging

Central Intake project that went live October 2018. These checklists have been made available digitally by

embedding them into EMRs and support to the primary care practitioners has been made available through

Pathway and RACE line.

Furthermore, this work has led to consultation with The Guidelines and Protocols Committee (GPAC) who are

developing a new BC Guideline on five diagnostic imaging recommendations tailored to BC primary care

practitioners. These recommendations include guidance around imaging for low back pain, imaging for minor

head trauma, imaging for uncomplicated headaches, imaging for joints, and imaging for pulmonary embolism.

The guideline builds on the five recommendations for BC developed by BC’s Quality, Performance, Service

Distribution Working Group on Medical Imaging, and is expected to be published in fall 2019.

The medical imaging projects have been

presented numerous times during the Radiology

Society of North American annual conferences.

The project “CT for lower back pain patients at

SPH ED“ has been published in Journal of the

American College of Radiology and the project

“MRI for major joints of severe osteoarthritis of

seniors at Vancouver Acute“ also has a work in

progress for publication.

Presentations & publications:

• “Why give two when one will do” – rapid fire presentation, 2019 BC Quality Forum;

• “Evaluating the impact of CST on lab orders“ - rapid fire presentation, 2019 BC

Quality Forum;

• Is Choosing Wisely a Wise Choice for Medical Imaging? – presentation, 2018 UBC

Radiology Grand Rounds;

• Imaging wisely: reducing inappropriate MRI exams to address long wait times in BC –

full session presentation, 2018 BC Quality Forum.

• Min A, Chan VWY, Aristizabal R, Peramaki ER, Agulnik DB, Strydom N, Ramsey D,

Forster BB. Clinical Decision Support Decreases Volume of Imaging for Low Back

Pain in an Urban Emergency Department. J Am Coll Radiol. 2017 Jul;14(7):889-899.

• Addressing Appropriateness: How to make choosing wisely the right choice – full

session presentation, 2017 BC Quality Forum.

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Physician Led Quality Improvement (PLQI)

Quality Improvement partnership among VCH, PHC and Specialist Services Committee (SSC) to strengthen the quality improvement capacity and culture within our physician community.

There are four components to our work:

• Sessional funding for QI projects;

• Accredited QI training;

• Physician QI advisors for coaching and

organizational navigation;

• Technical support including data analysis.

Since launching in 2017, the PLQI program has supported, trained and funded 43 physicians to find better

ways to take care of patients.

physicians funded21 physicians funded362017 2018

Dr. Matthew Kwok DEPARTMENT OF EMERGENCY MEDICINE

My experience in being part of PLQI cohort #2 has been exceptionally positive and rewarding.

PLQI has been instrumental in bringing my quality improvement idea into reality. The PLQI staff

has been extremely supportive and helpful. I cannot ask for a better team to assist me with my

project. In terms of professional development, the PLQI training I received allows me to have a

better understand of what quality improvement is all about. The seminars and online modules

give me knowledge and skills that I can use on a day-to-day basis.

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Accredited QI Training

All cohort physicians are required to attend 40 hr of advanced training over the course of 7 days.

physicians trainedone-day in-class

Intro to QI

training between

2017–2019

Intro to QI session

in Sechelt

would recommend

this training to

their colleagues

This accredited training session features teaching on Quality Improvement versus Quality Assurance;

research; model for improvement; working with QI data; human factors and patient engagement.

Often this course is the first introduction of physicians to the world of QI, and helps to identify and develop

improvement projects that may become eligible for funding within the PLQI program.

20211 1 89%

Physician participant

INTERMEDIATE TRAINING SESSION

Physician participant

COHORT TRAINING SESSION #8

All physicians need to know of this [training], overall quite useful. It has increased my interest in QI in general. Thank you!

Excellent session—learned a lot and feel supported! There is just so much to learn. I do find interacting with colleagues some of my best learning.

Cohort 2 OCTOBER 2018

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Improved the sense of community among

physicians, nurses, educators who take care of

these patients.

Specific impact of work

Dr. Mypinder Sekhon’s work, supported by the PLQI team, includes the implementation of a

neurocritical care program at VCH. The implementation of strategies for patients with traumatic

brain injuries, which allows for the optimization of the brains metabolism and for personalized care

of the patient, has led to ground-breaking outcomes for patients:

Dr. Kelly Mayson’s success in achieving a reduction in the incidence of anemia in gynaecology

oncology and radical cystectomy patients presenting for major abdominal surgery was due to a

significant increase in the referrals to the Perioperative Blood Management Program (PBMP) and

the treatment of iron deficiency anemia. The PLQI initiative enabled Dr. Mayson to lead a multi-

disciplinary working group physicians from multiple specialities and hospital staff to support the

quality improvement work. PLQI project team have provided complex data analysis and technical

support to consolidate and analyze large datasets to inform decision making.

The Specialist Services Committee has agreed to sponsor a patient optimization collaborative (SPOC) that will continue

their work over the next 12 months with funding through to September 2020.

Dr. Mayson completed a rapid-fire presentation on this work at the BCPSQC Quality Forum in February 2019.

Dr. Cole Stanley ’s work on “Best-practices in oral opioid agonist therapy collaborative” tested a

standardized clinical data entry form for all patients with a history of opioid use disorder. The PLQI

team provided programmers support, linked with Decision support, to create a form inside EMR to

collate specific metrics which propelled the work. He is medical lead for the BOOST collaborative,

in which quality improvement (QI) frameworks are used to promote system change and address

gaps in care with a goal of improving care for people with OUD. BOOST was rolled out provincially

on January 17th, 2019.

The PLQI work has also had an impact from an Operational staff perspective. The following quotes were collected during

a 2018 staff survey asking how the QI project impacted their day-to-day work:

https://vancouversun.com/news/local-news/a-bolt-drilled-through-the-skull-is-rescuing-patients-with-traumatic-brain-injuries-at-vgh

https://ourvancouvermsa.ca/2018/10/17/excellent-results-coming-in-for-project-funded-jointly-by-vpsa-facility-engagement-and-physician-led-quality-improvement-initiatives/

Physician

Nurse

Positively, better track of patients who were poorly

engaged, better clarity around the importance

of collecting and accurate data, better unity with

various providers around the type of care we should

be providing.“ “

Shanafelt TD, Gorringe G, Menaker R, et al. Impact of organizational leadership on physician burnout and satisfaction. Mayo Clin Proc. 2015;90(4):432-440

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Our team is conducting prototypes of the PULSE

leadership 360 and the Mayo Leadership Index,

to identify which tool is perceived to be more

valuable for providing insight and the usefulness in

professional development of medical leaders

A regular process for medical leadership

assessment will be established at VCH with the

goal of developing a sustainable, valued program of

leadership assessment and development supports

that can be implemented across the region.

The feedback will strictly be used to provide insight

for physicians to consider in the development of their

own professional skills and effectiveness as a leader.

It is also an opportunity to provide recognition of

effective leadership behaviors.

In conjunction with the assessment, Medical Leaders

will provide input on the development of a Medical

Leader Resource Centre, to ensure adequate tools

and resources are available.

Medical LeadershipSupporting the professional growth of our leaders to ensure clinical quality. Includes: Medical Leadership Assessment; Internal training programs; Resource Centre

I. Medical Leadership Assessment

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More about these WorkshopsOur team has developed an accredited

Physician Peer Coaching workshop that is

include reviewing assessment results and

creating learning plans together.

Coaching workshops based on the R2C2 model

(Sargeant et al., 2015) and the SCARF model

leaders to support participants facilitated

feedback to set personal practice goals

and create learning plans based on the MSF

feedback reports.

The Physician coaching workshop provides

hands on opportunities to both learn about MSF

(will include leadership assessment in the future

as well) and to practice providing facilitated

feedback to peers. Completion of a coaching

workshop is mandatory for leadership to attend

prior to launching the MSF within each site.

Small-group coaching workshops will teach

the following:

II. Resources / Workshops

• Coaching skills - how to create a positive

environment that is conducive to receiving

feedback and to identifying areas for practice

improvement;

• Tips and tricks to support goal setting and the

creation of learning plans;

• Material on what to expect around the MSF

tool: Reports and Development Plan

Physician participant

Useful coaching session. Great group for conversation. Very useful session; very well done.

Workshops Facilitators

Dr. Kevin Eva Dr. Vivian Chan Dr. Peter Gibson

“

Associate Director & Snr

Scientist, Center for Health

Education Scholarship,

Professor & Director of

Education Research and

Scholarship, Department of

Medicine UBC

Director, Medical Quality

Leadership & Practice

Program physician for Doctors

of BC’s Physician Health

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Our team leads and works in collaboration with others to create processes that can be leveraged

with MSA around engaging departments around wellbeing. We are also working collaboratively

and where possible, shape their organizational interactions.

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Medical Quality Leadership & Practice Team

FEBRUARY 2019

Additional information about our department

Or you may contact us directly at:

MedicalQuality@vch.ca

Contact Us

[Back row, left to right] Lily Nguyen, Vivian Chan, Ghadah Alkhulaif, Selina Wong, Jing Luo, Amy Chang, Rochelle Szeto, Rhythm Nagpal, Sheena Ng, Kanako Sato[Front row, left to right] Chenyu Zhang, Enrique Fernandez, Laurie Kilburn, Allison Chiu