Algonquin FHT

Atikokan FHT

Barrie CHC

Barrie FHT

Bramalea CHC

Brighton Quinte West FHT

Burk’s Falls and District FHT

Centretown CHC

City of Lakes FHT

Ear Falls FHT

East Ottawa FHT

East Wellington FHT

Elliot Lake FHT

Four Villages CHC

Grandview Medical Centre FHT

Greenstone FHT

Guelph FHT – Dawson Site

Halton Hills FHT

Hamilton FHT – Rosedale Site

London Centre of Hope FHT

Maitland Valley FHT

Maple FHT – Clergy Site

Merrickville CHC

North Hastings FHT

North Huron FHT

North Kingston CHC

North Lambton CHC

North Lanark CHC

North Perth FHT

North Shore FHT

North York FHT

Owen Sound FHT

Petawawa Centennial FHT

Points North FHT(formerly Machin FHT)

Port Hope CHC

Rapids FHT

Red Lake FHT

Seaton House FHT

Smithville Family Medical Centre FHT

South Riverdale CHC

Southlake FHT

Summerville FHT – Harbon Site

Wawa FHT

Windsor FHT

Woolwich CHC

Participating Teams From...

2

“Congress is not so much a graduation, but a commencement.”Nick Kates, QIIP Provincial Lead

Over a 14-month period, 51 primary healthcare teams from across Ontario participated inQuality Improvement and Innovation Partnership’s Learning Collaborative 3. While keepingpatient outcomes and experiences at the forefront, teams were able to demonstratesignificant breakthroughs in the domains of chronic disease management, preventativecare and office practice redesign. This is the story of their quality improvement journey.

MissionThe Quality Improvement and Innovation Partnership willbe the provincial leader in quality improvement methods

for primary healthcare.

VisionOntario’s primary healthcare system will be recognized as

providing exemplary primary healthcare driven by acommitment to continuous quality improvement.

GoalTo advance the development of a high performing

primary healthcare system.

3

The conclusion of Learning Collaborative 3 marks an

important milestone for the 51 teams that engaged in

improvements related to diabetes management, colorectal

cancer screening and office practice redesign. This report

reflects the efforts that teams have made to test, study

and implement changes in the interest of improving

outcomes of care for the patients they serve in

communities across the province.

This report also marks another milestone with the end of

the first three Learning Collaboratives that QIIP launched

in early 2008, when we began the exciting journey of

introducing quality improvement to primary healthcare

practices in Ontario. As we learn together, we have

benefited immensely from all 121 teams, across three

Learning Collaboratives that have been willing to share

their improvement journey with us.

It has always been our goal to build capability and

capacity for a made-in-Ontario approach to quality

improvement that would advance a high-performing

primary healthcare system. Our experience with the

Learning Collaboratives has confirmed our belief that

Ontario is poised to lead the way in the implementation

and spread of quality improvement approaches that will

help transform the foundation of our healthcare system,

which is primary healthcare. We have had the privilege of

seeing teams demonstrate the benefits of a team-based

approach to care, embrace rapid cycle tests and

measurement as a way of doing their daily work and

redesign their processes to ensure patients receive care

on their day of choice. It has been these experiences

shared during breakout sessions, on storyboards, as part

of regular team meetings and via the listservs that has

provided us with the motivation to explore new ways to

continue to support and spread the improvement efforts

of primary healthcare teams.

As we transition to the Learning Community, we look

forward to working together to learn, share, innovate and

improve in the spirit of Excellent Care for All.

Important Milestones for QIIPand Primary Healthcare TeamsMessage from Brenda Fraser, Executive Director

QIIP is a provincial organization funded by the Ministry of

Health and Long-Term Care with the goal of advancing

the development of a high-performing primary healthcare

system. This goal is supported by three interrelated

strategies: networking and partnerships, resources and

supports, and improvement and innovation methods.

QIIP’s vision1 for a long-term system of improvement in

primary healthcare recognizes the need to engage and

leverage strategic partnerships with other key

organizations and individuals at a regional, provincial,

national and international level. In this way, QIIP’s

activities can build, with others, toward shared outcomes

related to a healthier population, improved patient and

care team experience and more effective use of resources.

Primary healthcare renewal 2 has been identified in

Canadian policy and by most health reformers as the

foundation in a sustainable healthcare system. The

opportunity for primary healthcare to coordinate,

integrate and expand systems of care is defined by the

following:

■ Collaborative care teams

■ Sickness prevention, population health and health

promotion

■ Informed research, knowledge translation and quality

improvement

The need to build capacity and capability for quality

improvement in primary healthcare in Ontario is being

advanced by QIIP, initially through the implementation of

three Learning Collaboratives based on the IHI

Breakthrough Series3 methodology. Continued

engagement of primary healthcare teams in quality

improvement will be supported by the Learning

Community model and will include a virtual workspace

(see page 10) for teams to learn, collaborate, innovate and

measure their improvements. The Learning Community

was launched in spring 2010 with six content-specific

Action Groups. Participants will work towards sustaining

their improvements and will take on the challenge of

additional areas of focus in primary healthcare.

The focus on learning and building knowledge are the

underpinnings of quality improvement. Since May 2008,

QIIP has supported over 120 Family Health Teams (FHT)

and Community Health Centres (CHC) from across

Ontario. The collaboration of teams has provided a

structure for learning, sharing and action as they make

system-level changes that lead to improvements in care.

Before quality improvement work began, a primary

healthcare team had to be created. For it to be a true

collaboration, many different roles within the team

needed to be represented. The core teams were

composed of:

The Physician Champion (principal leader at the practice

site)

Clinical/Technical Experts (allied health team

members/front office staff)

Team Lead (day-to-day leadership and coordination)

Reporting Lead (monthly data collection, reporting and

communication)

A learning collaborative not only brings teams together

around shared goals, but more importantly, it is a highly

effective way to accelerate widespread improvement. A

Quality Improvement Coach provided external coaching

to the team around the integration and application of

relevant frameworks to support quality improvement.

The teams have engaged in quality improvement work

in three areas of focus:

Chronic Disease Care – Diabetes

Preventive Care – Colorectal Cancer screening

Office Practice Redesign – Access & Efficiency

Through the application of the Model for Improvement4

and the integration of the Plan-Do-Study-Act (PDSA)

Cycle for testing change, the participating teams have

realized innovative improvements in provider

satisfaction, processes and patient outcomes.

Collaborative Team

About QIIP

4

The Frameworks for ChangeThree frameworks supported the quality improvement

efforts of the teams: the Learning Model3, the Model for

Improvement4 and Chronic Disease and Prevention

Management Model.5 The frameworks assisted in closing

gaps that existed in the systems of care of the

participating teams and in doing so, built the capacity to

innovatively move towards planned care, panel

management and a population health focus.

Designed on the Institute for Healthcare Improvement’s

Breakthrough Series Model3, the QIIP collaborative

incorporated the following elements of the Learning

Model:

■ Three Learning Sessions, which included workshops,

teachings, didactic speakers, storyboard presentations

and team meetings

■ Action periods between each learning session where

teams tested change ideas using the improvement

methodology of the Plan-Do-Study-Act Cycle

■ Information technology was used to help manage the

flow of information, learning and activities. Teams were

encouraged to post their reports and data on the virtual

office and to communicate with one another through a

listserv, regularly scheduled teleconferences, and

phone and email correspondence

■ Quality Improvement Coaches well versed in the models,

frameworks, tools and data analysis were assigned to

each team to assist members throughout their

participation

THE ORIGINAL IHI LEARNING MODEL3

“BREAKTHROUGH SERIES”

5

MODEL FOR IMPROVEMENT4

CHRONIC DISEASE PREVENTION & MANAGEMENT FRAMEWORK5

Used during the Learning Collaborative, The Model for Improvement methodology is a strategy for testing,

implementing, and spreading practice innovations. It includes the use of PDSA cycles or rapid cycle tests

of change to drive improvement.

The Chronic Disease Prevention and Management Framework guides our work to affect system change. It

conceptualizes an approach to care by showing how interactions and relationships between various parts

of a system aim to improve population health outcomes

6

The Frameworks for Change

Not sacrificing quality for quantity is just one suggestion

from the City of Lakes FHT for building a culture of

quality improvement within an organization. Using a

simple reminder to book an annual diabetic visit has

resulted in a staggering 97% compliance rate among City

of Lakes FHT patients. The development of their Happy

Birthday Initiative and diabetic group visits, was

developed by surveying diabetic patients within the FHT.

Results from the survey guided the team in developing a

program based on the needs and wants of their diabetic

patient population and resulted in a cooperative

relationship with their local Diabetes Education Centre.

Pilot Population:Diabetic patients of Dr. Jack Ceaser

On the month of their birth, diabetic patients are called

with a reminder to book their annual diabetes review

appointment. Happy Birthday packages are mailed to

these patients, complete with a lab requisition, enabling

them to complete their blood work prior to the visit.

During patient visits, physicians are able to easily review

recent lab values, past visits and chart in the electronic

medical record, using the Annual Diabetes Review stamp.

Patients are given a copy of the Diabetes Passport and

referred to appropriate healthcare providers within the

team and community.

In an effort to spread this initiative staff disseminated

the information to the remaining physicians.

The focus on chronic disease management gave teams the necessary resources for proactive and planned care for

selected diabetic patients. Using a survey to develop their Diabetes Happy Birthday Initiative and diabetic group

appointments, City of Lakes FHT were able to increase the percentage of retinopathy screening and documented

patient self-management goals among their diabetic population.

Diabetes

CITY OF LAKES FAMILY HEALTH TEAM74% INCREASE IN DOCUMENTED SELF-MANAGEMENT GOALS

PERCENT OF DM PATIENTS WITH DOCUMENTED SELF-MANAGEMENT GOALS IN THE LAST 12 MONTHS FOR DR. JACK CEASER

“Real improvements occur when teams and systems are aligned.” David Courtemanche, Executive Director, City of Lakes Family Health Team

City of Lakes Family Health Team - Staying Focused on the Patient Experience

7

RETINOPATHYSCREENINGRATES ALSO

INCREASE FROM

23% to 83%

8

Addressing a mass mailing to patients 50 to 74 years of

age with the notice “Important Message from your Family

Doctor” enabled Barrie and Community FHT – Team 2 to

educate their patients regarding the importance of

colorectal screening with a simple at-home testing kit –

Fecal Occult Blood Test (FOBT).

Letters with an FOBT screening kit were mailed to

patients along with the request to complete the test

within seven days. Patients who did not complete the test

were sent a follow-up letter, and returned results were

documented in the Health Maintenance Category of the

electronic medical record.

Success Story

Through mail screening, two Barrie and Community FHT

patients were detected with positive FOBT results. One

patient in particular, who did not come into the office on

a regular basis, responded to the

letter and completed the screening.

The test was positive and as a

result, underwent surgery. Using a

quality improvement approach and

adapting a program that is targeted,

resulted in early detection and life

saving surgery.

Screening Approach Spread to Other Areas

Successful FOBT screening rates led Barrie and

Community FHT to spread preventative screening

measures to other domains (pap tests, mammograms,

flu shots and other immunizations) with 89% to 96%

successful screening rates.

“When a team talks and shares, things change.”Laura Back, Registered Nurse

“Through FOBTscreening wesaved two lives.”Dr. Andrew Wozniak,Physician, Barrie andCommunity FHT– Team 2

The improvement efforts in the colorectal cancer screening domain focused on prevention through the development of

screening processes. Testing changes and incorporating self-management techniques, to improve screening rates, has

demonstrated that increased numbers of patients could effectively receive education and preventative screening.

Colorectal Cancer Screening

BARRIE AND COMMUNITY FAMILY HEALTH TEAM AN INCREASE OF 29% TO 86% OF PATIENTS SCREENED

FOBT FOR THOSE >=50 AND <=74 YEARS WITHIN THE PRECEDING 2 YEARS OR COLONOSCOPYSCREENING FOR DR. ANDREW WOZNIAK

Barrie and Community Family Health Team – Positive Patient Outcomes

“Working with the Barrie and Community FHT –Team 2 was very inspiring to me. Thisteam found the balance between quality patient care and efficient office practices. This isevidenced by their impressive FOBT screening completion numbers and their statistics forcompletion of pap smear and mammograms. The winners in this improvement journey

are the patients and the healthcare team.” Dora-Lynn Davies, Quality Improvement Coach

9

Office Practice RedesignPrimary healthcare providers across Ontario are

redesigning how they deliver services to provide care that

is focused on “doing today’s work today”. Teams are

implementing changes that are improving access that is

effective, efficient, patient-centered and team based. The

results are significant as teams have enabled patients to

receive timely access to the care they need. Applying

principles that include measuring for third next available

appointment (TNA), cycle time and red zone time

(efficiency), has demonstrated an improvement in the

flow of work, created efficiencies and balanced the supply

of care to meet the demand.

SMITHVILLE FAMILY HEALTH TEAMREDUCTION IN THIRD NEXT AVAILABLE APPOINTMENT FROM 31-0 DAYS

AVERAGE TIME TO THIRD NEXT AVAILABLE APPOINTMENT FOR DR. PAUL CANO

Smithville Family Health Team – Improving Access and Efficiency for PatientsWith the goal of reducing the average time to the TNA,

the Smithville FHT made tremendous improvements in

the practice of Dr. Paul Cano.

Reducing Backlog

Adapting the methodology of ‘doing today’s work today’,

Dr. Cano and his team worked hard at understanding,

evaluating and reducing the appointment backlog by

incorporating the following changes prior to launching

advanced access:

■ Addressing patient needs at the time of their

appointments – initially made for longer days, but

reduced the amount of future follow-up visits

■ Tracked supply and demand by using an Institute for

Clinical Evaluative Sciences tool to determine if current

schedule could meet demand

■ Added extra clinic time and extended two daily clinics

over a three-month period

Informing Patients

Three months prior to the start of

advanced access, patients of Dr.

Paul Cano received a letter and

frequently asked questions

sheet, notifying them of the

new booking method, patient

advantages and the success of

advanced access in other

practices across Ontario.

Improved Outcomesand Successful Spread

The official launch of advanced access in October 2009,

has since seen improvements in a reduction of TNA from

31-0 days, reduced no-show appointments and increased

staff satisfaction. Advanced Access was successfully spread

to three other physicians within the FHT.

“Advanced access has dramatically improved my patients’ ability to see me at thestarting point of their health problem. Only having to wait one day has decreased

their stress, as well as the stress of me and my staff.”Dr. Paul Cano, Physician, Smithville Family Health Team

SIGNIFICANTIMPROVEMENT SMITHVILLE FAMILYHEALTH TEAMA REDUCTION IN THIRDNEXT AVAILABLEAPPOINTMENT FROM 31DAYS TO 0 DAYS

In spring 2010, QIIP launched Wave 1 of the Learning

Community – a place for primary healthcare teams in

Ontario to come together to learn, share, innovate and

improve. The goal of the Learning Community is to

support teams in building capability and capacity to

improve clinical, functional and population health

outcomes in primary healthcare in Ontario. The

participation response has been tremendous.

There are six content-specific Action Groups: Asthma,

COPD, Diabetes, Hypertension, Integrated Cancer

Screening (breast, cervical, colorectal), and Office Practice

Redesign being rolled out during this first wave. Similar

to the Collaborative format, teams are expected to report

and post their data, and will incorporate a newly designed

web-based infrastructure called the GATEWAY. Teams

will also be supported by an external Quality

Improvement Coach.

The opportunity to partner with The Lung Association,

Heart and Stroke Foundation of Ontario and Cancer Care

Ontario has been invaluable in supporting the

development of the Asthma, COPD, Hypertension and

Integrated Cancer Screening actions groups.

LearnModel of Improvement,Chronic Disease Preventionand ManagementFramework, evidence-basedClinical Practice Guidelines

SharePDSAs (tests of change),ideas, outcomes,challenges, strategies,successes, and developedresources

InnovateChange, improve, andcreate new processes / oldprocesses, and tools andsystem of care

ImproveRegular measurement of acommon set of measuresthat will indicate whetherchanges made are resultingin improvement

The Learning CommunityThe Next Step in the Advancement of Primary Healthcare in Ontario

News & Events

Keep up-to-date andinformed with thelatest news andevents pertaining toyour Action Group.

Team Reporting Centre

Customize team –created documents foryour practice.

Group Discussions

An important part ofsharing andinnovating, the GroupDiscussions area willallow teams to shareknowledge, ideas andresources with oneanother.

For more information on the Learning Community, or to view the Action Group Charters, go to

www.qiip.ca and click on the Learning Community GATEWAY tab.

The Learning Community GATEWAY – A Virtual Workspace Example

10

Charter, ChangeConcepts, MonthlyReport Templates,Pre-Work Manual,PDSA/Progress ScoreTemplates, TreeDiagram

Action Groups arefounded on evidence-based ClinicalPractice Guidelines.Supporting documentsare available to assistteams in testingchanges, measuringoutcomes andsustaining gains.

Acknowledgment

References1. Quality Improvement and Innovation Partnership (QIIP) website: www.qiip.ca

2. Commission on the Future of Healthcare in Canada, 2002; Standing Senate Committee on Social Affairs, Scienceand Technology, 2002; Health Council of Canada, 2005

3. IHI Breakthrough Series, A collaborative model for Achieving Breakthrough Improvement. Innovation Series, 2003,www.ihi.org

4. Model of Improvement: The Plan-Do-Study-Act (PDSA) cycle was originally developed by Walter A. Shewhart as thePlan-Do-Check-Act (PDCA) cycle. Langley GL, Nolan KM, Nolan TW, Norman CL, Provost LP. “The ImprovementGuide: A Practical Approach to Enhancing Organizational Performance.”

5. Ontario’s Chronic Disease Prevention and Management Framework:www.toronto.ca/health/resources/tcpc/pdf/conference_lee.pdf

ResourcesAssociation of Ontario Health Centres (AOHC) www.aohc.org

Health Council of Canada www.healthcouncilcanada.ca

Please note our new address and phone number.

CollaborativePlanning Group

Co-ChairsPeter McKenna, Merrickville and District CHC

Anne DuVall, Barrie and Community FHT

Anne Marie Graham, Southlake FHT

FacultyCheryl Levitt, Cancer Care Ontario

Eileen Patterson, Ontario Health Quality Council

Hertzel Gerstein, McMaster University

Mike Hindmarsh, Hindsight Healthcare Solutions

MembersLynda Chilibeck, Peterborough FHT

Johanne Mousseau, Anson General FHT

Jamie Read, Sherbourne FHT

David Wallik, Caroline FHT

Kathi Carroll, Hamilton FHT

Andrew Oakes, MOHLTC

ConsultantsRoger Chaufournier, CSI Solutions

Christine St. Andre, CSI Solutions

QIIP StaffNick Kates

Brian Hutchison

Brenda Fraser

Trish O'Brien

Susan Wheeler

QIIP Quality Improvement CoachesCheryl Chapman

Nancy Dahmer

Dora-Lynn Davies

Ruth Dimopoulos

Maria Ferguson

Evelyn Gillson

Tracy Howson

Liz Jackson

Michele Mach

Milo Mitchell

Karen Palmer

David Smith

Erica Snippe-Juurakko

Mary Sylver

Tanya Spencer

Alice Strachan

Tricia Wilkerson

Lorri Zagar

Melissa Brink

Pierrette Price Arsenault

Julie Baird

Ashley Campbell

11

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2345 Argentia Road, Suite 101 Mississauga, ON L5N 8K4T: 905-363-0490 | Toll Free: 1-877-794-7447 | Email: info@qiip.ca | www.qiip.ca