EZ Medicine Quality Council - SCIC Newsletter

EZ MEDICINE QUALITY COUNCIL-SCIC EZMQC-Strategic Clinical Improvement Committee -Quarterly Newsletter

“It was an absolute pleasure to see all the continued work and learnings happening across the zone. I enjoyed seeing previous projects spread to other areas, and continue on with the initial idea.

December 2018

University of Alberta -DoM and Alberta Health Services 2nd Annual QI Collaborative day-Nov 16th, 2018 Over 200 attendees came out to support EZ QI!

Culture is changing!”

Best QI Oral Presentation: Using Quality Improvement (QI) Methodology to Develop a Standardized QI Educational Curriculum for Internal Medicine Residents -Dr Caity Collins Best QI Project 2018: Reducing Inappropriate Lab Draws on Unit 5A4 – A Quality Improvement Initiative -Dr. Priyanka Mysore and Jordan Garside People Choice QI Project 2018: University of Alberta Hospital( UAH) Pet Healing Program: Determining Capacity, Capability and Clinical Outcomes for Program Improvement -S. Williams, J. Wilson and N. Veronovici

Quality Improvement Education PGME Sessions: Tuesday, February 5 8:00 am to 12:00 pm

Congratulations: RAH Preeclampsia Project Awarded Best of Three- Obstetrics, Junior Member for the oral presentation at the SOGC Annual Clinical and Scientific Conference AND awarded

Wednesday, March 6 12:30 pm to 4:30 pm (RAH)

the International Society of Obstetric Medicine (Amsterdam)- young inves-

Wednesday, April 24 12:30 pm to 4:30 pm

tigator travel grant

Thursday, June 6 8:00 am to 12:00 pm

Deprescribing Benzodiazepines QI Project Manuscript

To Sign up please email Shirley Auvigne <auvigne@ualberta.ca>

Accepted by BMJ Open Quality Excellence In Medical Student Research Five Medical Students that participated in summer 2018 QI projects had

Grants: Upcoming AHS Innovation Quality Fund Further information email:Janine.Cousineau@albertahealthservices.ca Deadline for Submission February 15, 2019 at 1600

their posters accepted for the inaugural UA Excellence in Medical Student Research event-Nov 26, 2018.

Dr Elaine Yacyshyn– Graduated from the Master of Health Quality from Queens University!

AHS Quality Summit Oct 2018 We were there!

3 Poster Presentations: 1.Rheumatology-Kaye Edmonton Rheumatology Clinic-Pre-visit Outpatient Planning- Improving Patient Preparedness for Clinic Visits-SCIC Physician Leader: Dr Elaine Y 2. Rehab Medicine-Grey Nuns Community Hospital: Improving Collaboration and Access to Rehabilitation for Stroke Patients SCIC Physician Leader: Jaime Yu 3. Obstetric Medicine-Royal Alexandra Hospital / Lois Hole Hospital: Reducing Excessive Laboratory Ordering for Preeclampsia Bloodwork: Be Hip Gone with PIH SCIC Physician Leader: Dr Winnie Sia

Featured Quality Improvement Projects University of Alberta Hospital (UAH) GIM ED Evening Service: Formalized on-call staff physician check-in In an effort to improve patient care, flow in the emergency department (ED), and improve efficiency, the general internal medicine (GIM) department at UAH has changed its on-call process. Currently, the ED GIM service is made up of three senior-resident run shifts over 24hrs to provide continuous ED coverage. The evening shift from 4pm to midnight also coincides in some of the highest consult and patient volumes in the ED. Therefore, a quality improvement initiative was proposed to encourage on-call GIM staff to check in with their senior residents in the ED at 1700hr and between 2100-to-2200hr and physically review patient cases with them at these times.

This change is intended to result in more direct staff oversight and support in the evening hours, and provide further clinical expertise during these hours, help with consult burden, and most importantly help with ‘hold-over’ patients. These are individuals who may not need admission, but often benefit from a GIM management plan, such as clinic follow-up. These patients would often sit overnight in the ED until they could be reviewed by the morning GIM staff. This process results in certain patients spending extended time in the ED and taking up beds, and in general, led to a slowdown within the ED. This then led to increased emergency wait times, patient volumes, etc.

This test of change ran from April to July, of 2018, and has shown a 15% reduction in the time that ‘hold-over’ patients are staying the ED and a 16% reduction in total consult time (hold-overs and other consults). Along with this, 80% of surveyed senior residents report feeling more supported, and nearly 70% of GIM staff, residents, and ED staff felt that this intervention has led to reduced numbers of patients being ‘held-over’ in the ED. Interestingly, this change cycle identified potential areas for further optimization in the design of our second PDSA which includes monitoring other metrics such as time to GIM consult and consult time. And further clarifying GIM staff responsibilities and roles during these check-in periods to further optimize the service. We will also explore GIM staff workload, as 45% of respondents reported that the changes have increased their overall workload.

This intervention has thus far produced some very promising trends and sets the foundation for further interventions and outcome measures that should help improve the way that the GIM ED consult service is run and improve the quality of care that we deliver to our patients.

Project leads: Dr Narmin Kassam and Dr Simon Taylor

https://www.aamc.org/cim/linkableblob/428872-1/data/spring2015transitiontoresidency-femaleresidentwithdoctor-data.jpg

GREY NUNS COMMUNITY HOSPITAL – EMERGENCY DEPARTMENT (ED) GENERAL INTERNAL MEDICINE (GIM) PHYSICIAN CONSULTATION AND TRIAGE PROCESS The Grey Nuns Community Hospital (GNCH) has approximately 75,000 ED visits annually with an average Emergency In Patient Length of Stay (EIP LOS) of 26-28 hours. GIM Physicians must care for both ward and ED patients simultaneously. This leads to GIM physicians working longer ward hours due to frequent pages and visits to the ED. Similarly, ED physicians must wait for available GIM physicians for consultations, have increased ED physician handovers and delayed ability to transfer patients to the wards.

Benchmarking of other Edmonton Zone (EZ) hospitals and a literature review provided insight into opportunities to impact the GIM physician schedule. Process assessment steps within the GNCH included multiple physician engagement sessions, a Gemba walk, a pre-post survey and a review of ED data. The main opportunity for improvement identified was the physical placement of a GIM consult physician directly within the ED from 0700-1700 Monday to Friday. A 3 month Plan-Do-Study-Act (PDSA) cycle to evaluate the service impact was completed. Supporting the change initiative and acceptance, frontline project champions led weekly sessions capturing real time issues along with solution tracking and supported consistent physician attendance at bed management meetings.

Preliminary results indicated a sustained decrease in the Average Length of Stay (ALOS) -ELOS ratio for PDSA #1. However, there was minimal impact on ED consult time and EIP LOS. Qualitative data suggested improvements in physician and bed management workflow, improved sign over practices and attendance of ward rapid rounds. Both desire for patient unit cohorting and trainee experience regarding continuity of care were identified as potential areas for further improvement to support the ED GIM physician service. Overall, change management approaches led to increased cultural acceptance and the development of and desire to pursue PDSA #2. http://www.esteworld.com/pictures/7262/1.jpg

Project leads: Dr Amanda Brisebois

and Lana Chivers

Sturgeon Community Hospital (SCH): From the Emergency Department General Internal Medicine Consultation and Triage Service (GIM-ED) to the Hospital Medical Consult Service (HMCS) (PDSA #2) Currently, within the SCH ED the medicine triage consultation (consult request to decision to admit) is delayed (out of the 2 hours AHS target) and patients are often not assigned to the most appropriate medical service team. Approximately ~2 hours/day a Medicine Physician is removed from the inpatient ward to perform ED consultations between the hours of 07001700. Delaying inpatient care and discharge processes. ED physicians faced with highly complex patients often debate which medical service should be consulted and batching of Medicine consultations requests result. All of the aforementioned, hinders the ED assessment timeframe, increases both workload and admitted patient boarding time in the ED. GOAL: Project aims to improve patient flow for medicine patients in the SCH ED by expediting medical consultation/disposition and allocation of admitted patients to the most appropriate medical service team.

Goal statement: within 6 months develop an ED Medicine triage and consultation service with the primary objectives of reducing the consult time for medicine patients by 20% as well as 20% reduction in the total ED length of stay for admitted and discharged patients, 15% reduction in “Door to Doctor” timestamp and 15% reduction in “Doctor to consult” timestamp Project Lead: Dr Hernando Leon

Improving Cervical Cancer Screening Rates in HIV-positive Women Cervical cancer is the 4th most common cancer in women, typically resulting from recurrent HPV infections. Survival rates are dependent on early diagnosis.

HIV-positive patients are at greater risk, with HPV infections progressing to cancer in a fraction of the time. Regular pap screenings allow for early detection of cervical cancer and help save lives. Current TOP guidelines recommend screening at least every 3 years for most adult women, and annually for HIV-positive women.

For HIV-positive women actively engaged in care in the Northern Alberta Program HIV clinics, only 72% are meeting current minimum screening guidelines. Even less meet the annual screening requirement for high-risk patients.

A major limiting factor is that overdue patients are not identified until the day before their clinic appointment. This disrupts clinic and nursing workflow and often results in the pap not being completed.

Many unscreened patients have a listed GP, but either are not being closely followed or, for personal or cultural reasons, are unwilling to have the GP complete the pap. Patient awareness was also a factor.

Interventions: Several interventions were initiated as of October 1st, in an attempt to close multiple gaps in the existing process: Recording pap information in E-clinician as part of the regular RN workflow, thereby proactively flagging patients overdue for screening prior to their appointment, and building clinic schedules accordingly.

Providing a hotlist of overdue patients to the booking clerk to assist in scheduling.

Stocking standardized pap kits to speed the process and minimize interruptions to workflow.

Improving patient education with pamphlets on screening, and encouraging ID physicians to discuss with patients.

Improving communication on screening between GPs and ID physicians via notes to GPs and the Alberta Referral Directory.

Project Leads: Dr Shannon Turvey, Dr Stephanie Smith and Dr Daniel Friedman

2019 EZMQC-SCIC Meetings: Access Partnership Project (APP) 

MOVED to Wednesday- Save the dates!

March 20, 2019

The results of the Access to Care Survey for the DoM.—a great deal of standardization has happened over the last year.



Final Edits to the Standard Operating Procedures Manual.



Final steps for Connect Care readiness within the department prior to the rollout of the IT system.

Special Thank you to Sandra Marini, her leadership in this project was amazing and very appreciated! Sandra has taken on a new role with ConnectCare, we will miss you!!!

June 19, 2019 September 18, 2019 December 4, 2019 Wishing You ALL a Wonderful Holiday Season!!!

Contact Us Pamela Mathura-QI Consultant pam.mathura@ahs.ca Dr. Narmin Kassam-Associate Chair, Clinical Affairs nkassam@ualberta.ca Yvonne Suranyi-Executive Directive EZ Medicine yvonne.suranyi@ahs.ca

EZMQC-Strategic Clinical Improvement Committee Dedicated to QI Capacity, Capability and Collaboration Visit Us: https://www.ualberta.ca/department-of-medicine/ezmqc-scic