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Friday, October 13, 2017 Medicine Grand Rounds 08:00 - 09:00 a.m. Poster Presentations 09:00 a.m. - 12:00 p.m. Bernard Snell Hall & Foyer

Strategic Clinical Improvement Committee 1

Partnerships in Action

Barbara Ballermann, MD Chair Department of Medicine University of Alberta

Quality is not an act, it is a habit – Aristotle In 2016, the University of Alberta, Department of Medicine recognized the need to build capacity for Clinical Quality Improvement (CQI) in order to realize our primary mandate of improving the health of Medicine patients in the Edmonton Zone. The overlapping strategic priority of CQI, presented the opportunity for a natural partnership with the Alberta Health Services (AHS), Edmonton Zone Medicine program and thus was born the Strategic Clinical Improvement Committee (SCIC). While education of faculty and learners is an important component of capacity building, doing is essential. Our physician CQI representatives from across the zone representing varying Internal Medicine divisions/sections and sites have been hard at work this past year, learning while doing QI projects. In most cases, residents and/or students have been engaged in the journey. Equally important has been the formation of partnerships within the AHS Quality Management Framework, facilitated by our SCIC Senior Quality Consultant, Pamela Mathura. The 1st Annual University of Alberta - AHS Medicine Quality Improvement Symposium on October 13, 2017 is a celebration highlighting the accomplishments of the members and partners of the SCIC. It is a showcase of how “Partnerships in Action” and teamwork are essential in building a culture of Quality Improvement in healthcare delivery and serving our patients.

Barbara Ballermann, Head, Clinical Department of Medicine AHS Edmonton Zone

Narmin Kassam, Co-Chair, Strategic Clinical Improvement Committee

Natalie McMurtry, Co-Chair, Strategic Clinical Improvement Committee

Quality Improvement Collaborative Day Table of Contents About the SCIC

SCIC Leadership

5-6

Acknowledgements

Brian Wong, MD

Keynote Speaker and Guest Adjudicator Associate Profess, & Director of Continuing Education and Quality Improvement iDepartment of Medicine, University of Toronto

Department of Medicine Grand Rounds - Deanâ&#x20AC;&#x2122;s Lecture Series

About the Day

Poster Scoring Criteria

Meeting at a Glance

Abstracts & Photo Voice Index

10 - 11

Abstracts & Photo Voice Presentations

12 - 47

Strategic Clinical Improvement Committee Partnerships in Action 4

About the SCIC

The University of Alberta (U of A) department of medicine (DoM) and Alberta Health Services (AHS) Zone Medicine Program had overlapping strategic priorities to develop a strong clinical quality improvement agenda and improve outcomes for medicine patients in the Edmonton Zone. As a result, the Edmonton Zone Strategic Clinical Improvement Committee (SCIC) was formed in alignment with the DoM strategic plan and the AHS quality management framework (QMF) supported by a DoM funded strategic clinical improvement consultant co-located with the administrative lead for AHS for Edmonton Zone Medicine. The primary mandate of the SCIC is to build organizational capacity for clinical quality improvement (CQI) within the DoM at the University of Alberta and within the Edmonton Zone Medicine Programs at five major sites.

SCIC Leadership

Narmin Kassam, MD, FRCPC Director, Division of General Internal Medicine Associate Chair, Clinical Department of Medicine, University of Alberta Dr. Kassam is Professor of Medicine at the University of Alberta. She is currently the Department of Medicineâ&#x20AC;&#x2122;s Associate Chair, Clinical, and the Director, Division of General Internal Medicine (GIM). Her clinical practice encompasses in-patient and ambulatory consultative GIM, she supervises medical students and residents at various levels of training.

She is currently leading the Department of Medicine Quality Improvement (QI) efforts in linkage with AHS and co-chairs the Strategic Clinical Improvement Committee (SCIC) that is undertaking various clinical QI initiatives in the in-patient and ambulatory settings in the Edmonton Zone. Dr. Kassam has been involved with the National GIM Residency Training Program Directors Committee which was instrumental in advocating for recognition of GIM as a distinct discipline at the Royal College of Physicians and Surgeons of Canada (RCPSC), since its inceptions. She serves as Vice-Chair of the GIM Specialty Committee at the RCPSC which developed the GIM document suite currently in use and will take over as Chair in 2018 when GIM is slated to adopt Competency Based Training. She is currently serving as Governor for the American College of Physicians, Alberta Chapter.

Teamwork: Coming together is a beginning Keeping together is progress 5

Working together is success!

Natalie McMurtry, BscPharm Executive Director, Medicine & Surgery, Alberta Health Services, Edmonton Zone Natalie is Executive Director of Medicine, Surgery and Operative Services at the University of Alberta Hospital and has strategic responsibility for medicine across the Edmonton zone. Her portfolio includes approximately 400 medical and surgical beds across a wide range of specialities including: pulmonary, nephrology, general internal medicine, trauma, general surgery, orthopedics, urology, plastics and ENT. Prior to taking on this role Natalie has worked in pharmacy operations and is a licensed pharmacist. At home, Natalie has four beautiful children and enjoys playing tennis.

Pamela Mathura, MBA B.Sc. MLS Senior Strategic Clinical Improvement Consultant, SCIC Pamela is Senior Strategic Clinical Improvement Consultant and a Clinical Lecturer for the University of Alberta Department of Medicine and Alberta Health Services -Edmonton Zone Medicine. Her role as the quality lead for the Strategic Clinical Improvement Committee (SCIC) includes leading Quality Improvement (QI) teams and QI training. Previous to this role Pamela has worked as a clinical quality consultant within Alberta Health Services. She has been involved in many large multi-Hospital QI projects which have been shared locally and provincially. Involved in healthcare service delivery for the last 25 years; her clinical background is in Laboratory Medicine and is a licensed Laboratory Technologist.

ACKNOWLEDGEMENTS The SCIC committee would like thank the people and organizations who took part to make this day possible.

Department of Medicine Grand Rounds in partnership with the Deanâ&#x20AC;&#x2122;s Lecture Series

Keynote Speaker & Guest Adjudicator (for poster presentations)

â&#x20AC;&#x153;Building Capacity for Quality -- How Can Academic Departments Lead?â&#x20AC;? Talk Objectives: 1) Reflect on the urgent need to build capacity for QI in academic departments 2) Describe key structures and processes that can enable academic success in QI Dr. Wong received his MD and subsequent specialty training in General Internal Medicine at the University of Toronto. After completing his residency training in 2007, he undertook a research fellowship in patient safety funded by the Canadian Health Services Research Foundation. As part of this fellowship, he became certified as an Improvement Advisor through the Institute for Healthcare Improvement in Boston, Massachusetts, and completed the Education Scholars Program at the Centre for Faculty Development at the University of Toronto. He is actively involved in delivering patient safety and quality improvement training to learners across the learning continuum. Over the past 5 years, he has trained several hundred trainees and faculty through various educational activities at the local and national level. His research the sits at the intersection of quality improvement, patient safeDr. Brian Wong ty and medical education has helped to advance our collective knowlAssociate Director & Site Director, Sunnybrook Health Sciences Centre- edge for how best to teach quality improvement and patient safety and Keynote Speaker Guest Adjudicator integrate these concepts into training. (for poster presentation)

He is a member of steering committees focused on establishing national faculty development strategies in quality and safety at both the Royal College of Physicians and Surgeons of Canada. Other research interests include improving the reliability of in-hospital paging communication, studying the unintended consequences of computerized provier order entry systems, evaluating the impact of error disclosure training, and implementing and evaluating the use of a near-real time trigger tool to

First Annual Quality Improvement Collaborative Day The first annual Department of Medicine and Alberta Health Services Collaborative day celebrates one full year of Quality Improvement (QI) learning, capacity building and the forming of many new partnerships. The scholarly inclusion of QI in medical education is an exciting new horizon. Healthcare over the last decade has introduced total quality management which is a management strategy aimed at embedding both the awareness of quality and quality methodology into clinical service processes. Supporting the development of a quality culture where care providers, daily seek to improve care, experience and safety. Within a few short months over 100 Physicians, Residents, Students and AHS leaders have been formally trained in QI. The QI project posters showcased today represent the effort of many AHS care providers led by Physicians and Residents with support from students. The projects range from small local improvements to system transformation. I have the extreme privilege to be part of the SCIC and as the quality lead for SCIC I am very proud of the teamsâ&#x20AC;&#x2122; effort, dedication and commitment to pursue QI. Support the teams today by asking questions and sharing your insight to enhance the work underway!

Poster Scoring Criteria

Clarity of the Improvement - Problem and Aim statements

1 2 3 4 5

Appropriateness of QI methods used to review the problem

1 2 3 4 5

Incorporation and/or Impact to patient experience/engagement

1 2 3 4 5

Relevance of the PDSA interventions to the Aim statements

1 2 3 4 5

Suitability of the improvement being shared (scaled and spread) to other units/hospitals 1 2 3 4 5 Impact to health outcomes and/or financials

1 2 3 4 5

Visual poster layout and visual impact of photovoice

1 2 3 4 5 TOTAL SCORE

Meeting at a Glance Time

Title

Speaker/Facilitator

Location

Medicine Grand Rounds - Deans Lecture Series 08:00

Title Opening Remarks/Introduction

Dr. Barbara Ballermann

08:00 - 09:00

Keynote Speaker – Dr. Brian Wong - Director of Continuing Education & Quality Improvement, Department of Medicine, Dr. Brian Wong University of Toronto & Associate Director for the Centre for Quality Improvement

Bernard Snell Hall

Edmonton Zone Medicine Program Strategic Clinical Improvement Committee 09:00 - 09:30

Opening Remarks

Dr. Narmin Kassam & Natalie McMurtry

Bernard Snell Hall

09:30 – 11:30

QI Project Symposium Poster Tour

Pamela Mathura

Bernard Snell Hall Lower Foyer

11:30 – 12:00

QI Project Poster Judging and Award Presentation

Dr. Brian Wong

Bernard Snell Hall Lower Foyer

11:30 – 12:00

Final Remarks and Poster Presentation Closing

Dr. Narmin Kassam

Bernard Snell Hall Lower Foyer

12:15 - 13:00

A light lunch will be provided Invitation Only

Respiratory Health Strategic Clinical Network

Bernard Snell Hall Upper Foyer

Improving Care for Patients with COPD 13:15 - 14:15

Rumble with the COPD bundle

Dr. Mike Stickland and Lesly Deuchar

Classroom D 2F1.04 WMC

14:15 - 15:15

Respiratory Presentation - Exploring the Landscape of Distress in Advanced COPD

Dr. Ron Damant

Classroom D 2F1.04 WMC

Next Steps in Edmonton Zone COPD Care

Edmonton Zone Respiratory Steering Committee Co-Chairs: Dr. Ron Damant and Carol Anderson

15:15 - 15:30

Classroom D 2F1.04 WMC

Strategic Clinical Improvement Committee Partnerships in Action 9

Poster Presentations

Bernard Snell Hall Foyer, 2F1.04 WMC Poster #

Author(s)

Project Title

Sponsors

Page #

X. Thompson, W. Sia, P. Mathura, A. Wong

Royal Alexandra Hospital / Lois Hole Hospital: Reducing Excessive Laboratory Ordering for Preeclampsia: Be HIP, Gone with PIH

W. Sia & J. Clink

30-31

A. Gantayet, A. Fong, P. Mathura, F. McAlister & N. Kassam

High-users of Acute Care: A Deeper Dive into Predictive Patient and System Factors

N. McMurtry & C. Osborne & D. Taylor

32-33

N. Kassam, N. McMurtry, P. Mathura, S. Marini & H. Choi

Edmonton Zone, Department of Medicine Access Partnership Project (APP)

B. Ballermann & N. McMurtry

34-35

J.C. Yu & P. Mathura

Improving Collaboration and Access to Rehabilitation for Stroke Patients at Grey Nuns Community Hospital

L. Chivers, M. Siddiqui, N. Kassam & N. McMurtry

36-37

N. Kassam, X. Sun, J. Keegan, D. Sinclair, P. Mathura, J. Zhang, & B. Sevcik

University of Alberta Hospital Admission Protocol Impact on Emergency Department and Patient Flow

C. Osborne & D. Taylor

38-39

F. Carr, P. Tian, J. Chow, J. Guzak, J. Triscott, P. Mathura, X. Sun & B. Dobbs

Glenrose Rehabilitation Hospital (GRH) Deprescribing Benzodiazepines: A Quality Improvement Initiative

H. Kammerer & A. Bertagnolli-Hansen

40-41

D.H. Lee, P. Mathura & N. McMurtry

Mealtime Companionship Program at the University of Alberta Hospital: a study on the views of patients, volunteers, health care providers, and relevant stakeholders

N. McMurtry N. Veronovici & F Robinson

42-43

K. Aziz, S. Shivananda & N. Singhal

The EPIQ workshop: simulation-based quality improvement learning for clinical teams

University of Alberta Department of Pediatrics, University of British Columbia, University of Calgary

44-45

N. McMurtry, N. Kassam, & P. Mathura

Building Organizational Capacity for Clinical Quality Improvement in an Integrated Academic and Large Health System

B. Ballerman C. Osborne & D. Taylor

46-47

University of Alberta Hospital Understanding Unnecessary Laboratory Testing on Internal Medicine Wards AUTHOR NAMES: I.Toman, N. Kassam, P. Mathura and J. Crawford SPONSOR NAME(S): N. McMurtry and EZMSA INTRODUCTION: The Canadian Choosing Wisely campaign recommends against routine complete blood count (CBC) and chemistry testing in the face of clinical stability in the inpatient Internal Medicine (IM) setting. At the University of Alberta Hospital (UAH), we hypothesized that overutilization of lab tests on IM wards occurs frequently. Our aim was to confirm that unnecessary lab ordering is a problem at our institution, understand the nature of this problem, and develop a quality improvement intervention to reduce unnecessary lab testing by 10% over a one-month study period. METHODS: Laboratory services provided six months of lab data from IM units, which was analyzed to determine the most frequently ordered lab tests. A chart audit and survey of IM residents was done to understand lab ordering practices. Process mapping was completed by frontline healthcare providers, a unit clerk and a lab representative, led by a senior quality improvement consultant. Based on these findings multiple Plan-Do-Study-Act (PDSA) cycles were implemented on an IM unit. The primary outcome measure is the total number of CBC, electrolytes, creatinine and urea tests done on the intervention unit compared to a control unit. Secondary outcomes include frequency of lab tests ordered as ‘daily’, and satisfaction of frontline unit staff. RESULTS: Analysis of six months of lab data showed that CBC, electrolytes, creatinine and urea account for more than 50% of all lab tests performed. A chart audit indicated that 69% of patients have daily lab tests ordered at admission and daily lab testing is always bundled. A survey of IM residents demonstrated that 97% of residents admit to ordering CBC daily at admission in over 75% of patients and 92% felt inappropriate lab ordering is a problem – the primary reason for this being department culture. Process mapping identified that physicians are often unaware when patients have daily lab tests, and lack a formal process to review inpatient lab orders. Multiple PDSA cycles were completed, which consisted of education, process change to improve communication of lab orders between the unit clerk and physicians, and a clinical decision support in the patient chart. A run chart of the total number of lab tests over time demonstrates a downward trend in lab testing on the intervention unit compared to the control unit. The intervention unit saw a 10% decrease in the total number of lab tests ordered. This is a saving of approximately $8536.00 on one 18-bed unit for a 6 month period. Applied to the five 18bed IM units at the UAH which have similar practice patterns, this could be over $80,000 per year in cost savings with minimal intervention in lab cost alone. The number of ‘daily’ tests on the intervention unit also decreased during the intervention. Unit staff and physicians found the process changes to be helpful and sustainable. CONCLUSIONS: Through this project, we have learned that culture and communication gaps are driving forces behind lab overutilization on UAH IM wards. By involving relevant stakeholders to help understand the problem, we have initiated a quality improvement intervention on one IM unit. Future plans include changes to the admission order form, and spread of the project throughout the IM department. 12

As medical providers, we all work hard to diagnose our patientsâ&#x20AC;&#x2122; problems and to treat their medical issues as quickly as possible. We never want to miss a diagnosis. Often, because of this culture and fear of missing something, we order many blood tests â&#x20AC;&#x201C; likely too many. Sometimes we become focused on the numbers we get from the laboratory, and forget about the painful needle pokes and bruises left behind. Our project is aimed at reducing unnecessary blood tests on Internal Medicine patients in hospital. We want every test to be ordered after careful thought. We want our patients to know what blood test we are doing, why we are doing it, and what the result means to them. We want to avoid painful needle pokes, when possible, and the anxiety and apprehension that comes with multiple tests. Ultimately our goal is to provide excellent patient care and to involve the patient and family as much as possible along the way. Behind every lab test is a patient who was awakened at 6 am, afraid of another needle poke and uncertain of what that test would reveal. This should be in all of our minds every time we order tests.

Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 13

Sturgeon Community Hospital (SCH) Emergency Department(ED) General Internal Medicine Physician Consultation & Triage Process AUTHOR NAMES: H. Leon, P. Mathura, N. Stephens, K. Maier and C. Salguero SPONSOR NAME(S): W. Tanaka-Collins INTRODUCTION SCH ED consultation for medical services is delayed (out of the 2 hours Alberta Health Services target) and patients are often not assigned to the most appropriate medical service team. For ~ 2 hours each day, physicians from medical teams are removed from the inpatient ward to perform ED consultations between the hours of 0700-1700. ED physicians faced with highly complex patients often debate which medical service should be consulted, which then results in batching of consultations. Approximately ~1.5 hours per day, an ED physician is involved in Medicine consult discussions, this increases ED physician workload and patient boarding in the ED. Along with the aforementioned, decompensated patients with multiple comorbidities may be admitted to a medical service ward that does not meet their full medical needs based solely on bed availability. Project aims to improve the Medicine patient flow in the SCH ED by expediting medical consultation/disposition and allocation of admitted patients to the most appropriate medical service team. METHODS Systematic process review involved the use of quality improvement methods such as conducting a Gemba walk, cycle time analysis, process mapping and a detailed review of ED metrics. Benchmarking with other local hospitals provided insight into the impact of physician roles, responsibilities and scheduling. Opportunities for improvement was also identified, one of such is the placement of a Medicine service consulting physician within the ED. A 3-month PDSA (plan do study act) cycle was employed to test the identified intervention. RESULTS Preliminary GIM results indicated a noticeable decrease in most ED measures. The consult time frame decreased each month by 38%, 22% and 25%. Qualitative data of ED physicianâ&#x20AC;&#x2122;s perception indicated impact to patient safety, joint decision making, ED efficiency and relationship building. Improved the quality of care for admitted patients as the appropriate medical service team was assigned. However, sustainment of the measures and having a Medicine service consulting physician in the ED requires further refinements to support coverage of physiciansâ&#x20AC;&#x2122; inpatient, preadmission clinic and ED responsibilities. Impacting cultural change and project resistance is challenging. CONCLUSIONS Improvement intervention demonstrated the direct impact that the Medicine service consulting physician has on both the ED and inpatient unit processes; supporting hospital wide patient flow. Impacting quality of care through timely consultation and appropriate medical service team assignment. Impacting cultural change and project resistance is challenging however; this project as motivated physician (ED and Medicine) teams to pursue continued improvement.

“Just how long is too long to wait in an Emergency Department, and what could we do differently?” The Emergency Department (ED) is busy with a flurry of activity but every day it seems to be the same. Many patients are waiting anxiously in the waiting room to see a physician. The wait can be hours long and this is exhausting for patients. The Sturgeon Community Hospital wanting to improve the ED consultation process, has developed an Internal Medicine consultant physician service that places the consultant physician in the ED working along side the ED physician. This allows for faster, joint decision-making among the ED physician, consultant physicians and shorter wait times for the patient. A specialist physician agreed that this “Improves patient safety” and the ED physician stated this has provided for “Timely and efficient hospital admissions”. There is no reason why we cannot improve. Our patients deserve nothing less! Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 15

COPD Patients Co-design Strategy for Seamless Hospital Discharge AUTHOR NAMES: L. Deuchar, M. Michas and M. Stickland SPONSOR NAME(S): Alberta Innovates (Partnership for Research and Innovation in the Health System program); Respiratory Health Strategic Clinical Network INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a common, chronic progressive lung disease with a predisposition to acute exacerbations resulting in frequent emergency department (ED) visits and hospitalizations. COPD exacerbations constitute the greatest proportion of preventable hospitalizations and hospital readmissions of major chronic diseases. At discharge, COPD patients are often unaware of or not connected to community supports, which can lead to exacerbation of their condition requiring readmission. This work seeks to strengthen collaboration between acute and primary care for better patient outcomes. METHODS: In this study, we want to achieve two objectives: 1) adapt an evidence-based consultation-driven COPD discharge bundle to be used in hospital and ED settings in Alberta to help patients stay at community after initial discharge; and 2) assess the effectiveness and cost-effectiveness of such bundle, delivered alone or facilitated by a dedicated case navigator to further improve patient-centered and economic outcomes and to reduce ED and hospital readmissions. We developed an evidence-based consensus-driven COPD discharge bundle through consultation with patients, providers, and administrators. This bundle was integrated into the provincial Acute Exacerbation COPD (AECOPD) Admission Order Set and currently is being implemented in locations province-wide. Half the patients receiving the bundle will also be randomized to care navigator support. We maintained a patient-centered focus to the development of the discharge bundle; acknowledging that patients partnering with their care providers is one success strategy in creating seamless patient care transitions. Patient focus groups were conducted in the development phase of the project to identify barriers and facilitators to successful hospital and ED discharges. RESULTS: We expect care for COPD patients discharged from the ED/hospital to the community to be guided by clear processes for care outlined by the COPD pathway; translating into better patient-centered outcomes, less hospital and ED visits and subsequent savings to the health system. Early findings are being measured through AHS Analytics Discharge Abstract database and scorecard methodology for improvement with local teams. An economic evaluation is also planned. CONCLUSIONS: By using Knowledge Translation strategies and an implementation trial for evaluation, this project identifies key factors for the scale and spread of the COPD discharge pathway across the province, and provides an evaluation of its impact on patient, provider and process outcomes.

Implementing a COPD Order Set Bundle to Improve Transitions in Care AUTHOR NAMES: C. Walker, C. Kawalilak, L. Deuchar and M. Michas SPONSOR NAME(S): Respiratory Health Strategic Clinical Network, Alberta Health Services INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is a common and progressive lung disease for which there is currently no cure. Accounting for some of the highest admission rates of all chronic diseases in Alberta, COPD costs the healthcare system over $1.5 billion annually. Individuals with COPD experience long hospital stays, high readmissions, and frequent emergency room visits―leading to decreased time at home and in the community. Our primary objective was to integrate acute, community, and primary care to facilitate transitions across the patient’s healthcare journey. Secondary, we aim to reduce hospital length of stay (LOS) and readmission, as well as improve patient experience. METHODS: Evidence-based COPD order set bundles were implemented―providing standardized patient care with focus on patient education, care satisfaction, and transition to community care. Collaboration with various physician groups, senior leaders, managers, front line staff, patients and families was obtained through meetings, focus groups, surveys, community inventory mapping and integration of parallel initiatives. A local improvement team was established with representation from frontline and community/ primary care programs. RESULTS: COPD order set bundles had an average 13.6% uptake from March to July. Patient transition from acute to community/primary care increased by 38.4% on average. Average and median LOS decreased by -7.2% and -28.6%, respectively, since implementation. Further, 7-day readmission decreased by an average -11.8% (-1.6% of total site discharges for COPD), since implementation. However, 30-day readmissions increased by 10.4% (1.1% of total site discharges for COPD). Patient satisfaction with quality of care/education was an average of 91.4%. CONCLUSIONS: Results indicate that order set bundle use was associated with improved patient transition from acute to community/primary care, decreased LOS, 7-day readmission rates, and increased patient satisfaction with care/education received. Order set bundles are available provincially with teams and support resources to assist with local integration of acute, primary and community care programs. Initiatives used to promote collaboration, communication and integration for support of the patient journey are adaptable to local settings.

Edmonton Zone INSPIRED COPD Collaborative - Transcendent Care of Complex Populations AUTHOR NAMES:

A. Hirji, D. Faulder, N. Kassam, C. Paul, P. Mathura, C. Anderson and N. McMurtry

SPONSOR NAME(S):

S. Valaire, M. Bhutani, R. Damant, I. Mayers, K. Sidoroff, A. Murphy, K. Liu, K. Lindroth, W. Robson & C. Eleniak

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is the leading cause for emergency department (ED) visits, acute care (AC) admissions and readmissions for Alberta Health Services (AHS), Continuing Care (CC) Programs, Edmonton Zone (EZ), provincially, and for Canada as a nation. COPD seldom presents in isolation as a medical diagnosis, with most individuals experiencing numerous co-morbidities and social challenges contributing to lives of great complexity. Individuals with more advanced stages of COPD live with debilitating breathlessness, dependence on oxygen, increased home-boundedness and isolation, functional changes and diminished independence. Frequent episodes of crisis breathlessness and acute exacerbations of COPD (AECOPD) have traditionally brought those with advanced COPD into frequent contact with Emergency Medical Services (EMS), ED and AC systems. Currently, there is no transcendent model of care for complex and vulnerable COPD patients in the EZ that crosses the continuum of care. This lack of integration promotes waste and waits, delays care, increases patient transitions, and results in poor patient and family experiences and outcomes. In December 2016, following a successful EZ Home Living program, called the INSPIRED COPD Initiative, the University of Alberta Hospital (UAH) and CCEZ began collaboration on a model of integrated COPD care for patients with advanced disease.

METHODS

Phase One: A report identifying 404 unique patients admitted to UAH inpatient medical and surgical units from September 1, 2015 to September 1, 2016 with a most responsible diagnosis of AECOPD was requested. Sixty-six unique patients had 2 or more inpatient stays during this time, for a total of 196 admissions. Seventy-one data elements were developed into a comprehensive chart audit tool to determine individual, medical, and system characteristics which impact patient lives. Phase Two: Process mapping was completed with 41 frontline care providers over 2 days representing EMS, AC, ED, CC and other community partners using quality improvement (QI) methods to identify areas of integration, fragmentation, hurdles and existing EZ COPD resources.

RESULTS

Chart Audit: Individual Characteristics: patients are elderly (71), live in an urban setting, have no legal guardian, have few informal supports (55%), use a mobility aide, are on home 02 (64%), are/were smokers (98%), have many co-morbidities (18), have had numerous UAH ED visits (5), and a UAH inpatient length of stay (LOS) of 13.5 days. Half the patients had between 1â&#x20AC;&#x201C;3 additional inpatient stays, and the likelihood of readmission for AECOPD within 30 days of discharge was 53%. Medical Characteristics reflected: complex admissions, thorough work-ups based on UAH guidelines, difficulty accessing PFT results, frequent medical consultations (71%), challenges with ongoing dyspnea management, and other complex medical issues. System Characteristics: 75% of patients arrived via EMS, the average CTAS score was 2, average stay in ED was 7.5 hours, little evidence of patient education during the stay was documented, few individuals were referred to community partners for follow-up on discharge, 94% of patients were at high risk for readmission based on their LACE score, only 50% of the time family physicians (FP) were notified of the discharge, 80% do not have a FP who completes home visits, only 51% of the patients are linked with a CC program on discharge, and 89% are not connected with other community supports for their COPD. Process Mapping: Comprehensive current state process mapping identified 358 hurdles, 231 system solutions and 90 existing EZ resources. Arising from the process mapping were 12 themed recommendation categories from which project teams will be developed.

CONCLUSIONS

Results from Phase 1 and 2 have informed next steps. In late 2017, activities for Plan, Do, Study, Act (PDSA) cycles will begin by teams involved in the EZ COPD collaborative involving: patient and family centred assessments, medication optimization, discharge planning, patient, family and staff education, strengthened transitions with supports and resources in the community and exploring system solution problem-solving.

COPD- No longer just a four letter word. In Canada, Chronic Obstructive Pulmonary Disease (COPD) is the number one reason for Emergency Department (ED) visits, acute care admissions, and readmissions. COPD is a progressive disease, with severe breathlessness, a significant life limiting factor. Often as the disease worsens, patients seek care in EDs to manage their symptoms because homebased options are not available. In 2015, one AHS team, the Edmonton Zone Home (EZ) Living Program, participated in a 19 team Pan-Canadian COPD Collaborative. The outcome: development of a patient-centred complex community COPD care model for the EZ. Bucky Stochinsky was one of the original INSPIRED COPD patients. For more than 20 months, care was managed in Bucky’s home, with the love and support of his family. In a national interview with the Canadian Foundation for Healthcare Improvement, he shared: “I am doing things I never thought were imaginable…They have given me back the quality of my life by caring for me in my home…allowing me choices and opportunities I have not had in years.”

Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 19

Kaye Edmonton Clinic - Patch Testing Evaluation AUTHOR NAMES: J.F. Elliott, P. Mathura, A. Wong, S. Holmstrom and S. Marini SPONSOR NAME(S): S. Larson and M. Melia INTRODUCTION In patients with suspected allergic contact dermatitis, patch testing is used to confirm the diagnosis and identify what is causing the problem. A variety of substances are applied to the patientsâ&#x20AC;&#x2122; skin to determine if they lead to an allergic reaction. In theory, by informing the patients about what substance (or substances) they are allergic to, they should be able to achieve full recovery, provided they are able to avoid the offending agent(s). There remains a need to assess the effectiveness and utility of the patch testing and follow-up education process, which will provide important information about how this process can be improved. METHODS A follow-up survey was sent to patients who had received patch testing from January 2016 to July 2016. The aim of the survey was to assess patient perceptions about the usefulness of patch testing, and whether the test helped the patient manage their contact dermatitis. In August 2017, 223 patients who showed at least one positive allergen and provided an email address at the time of patch testing were sent an email inviting them to complete an online survey about patch testing. The email provided a hyperlink that took them directly to the survey. RESULTS Of the 213 patients who received the email, 69 completed the survey. The majority of patients (88.4%) stated they would recommend patch testing to friends or family with a similar rash. A slightly higher number (92.8%) agreed that patch testing helped inform them which substances caused their allergy. However, only 75.4% of respondents believe that patch testing helped them manage their contact allergy. 42% of respondents were able to recall all the substances they were allergic to, and 52.2% of patients could recall some of the substances they were allergic to. 68.1% of patients reported that their rash improved after patch testing. CONCLUSIONS Although the majority of patients found that patch testing helped them manage their contact allergy, there remains opportunity for improvement. Possible interventions suggested by patients were to provide a more detailed list of substances to avoid, have patients bring in more products that they react to for patch testing, formalize follow-up appointments with their referring dermatologist, and develop more user-friendly ways for patients to remember what they are allergic to. To support these suggested interventions (and others), we are undertaking the development of detailed referral guidelines for patch testing that will be accessible to all referring dermatologists.

Many patients come to our Patch Test Clinic both frustrated by their persistent rash and a bit nervous about having to undergo such an involved test. They describe the redness, swelling, and itching of their skin, and the detrimental effect this has on their daily lives. “Can you please just tell me what I’m allergic to doc?” the patient asks, “It’s been driving me crazy! I need to know what to avoid.” One day, I ran into one of my patch test patients, who greeted me smiling and enthusiastically pointed to where her rash used to be. Where there were once red, raised, scabbed-over, oozing circular lesions, now there were only faintly colored spots. We want all patients to have a similar result. By letting them know what things to avoid as a result of their patch test results, they can cure their own rash by simply switching to products that do not contain their allergens. As my former patient walks away smiling, I am reminded of the positive impact that patch testing can have, allowing these patients to get back to their lives rash free!

Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 21

Reducing the Incidence and Severity of Post-Operative AKI at the University of Alberta Hospital, and Nursing Perceptions Towards Post-Operative AKI. AUTHOR NAMES: R. C. Herman, P. Mathura and N. Pannu SPONSOR NAME(S): N. Kassam, N. McMurtry and D. Kozitsky INTRODUCTION: Patients undergoing operative procedures have a high incidence of in-hospital acute kidney injury (AKI) that is often under recognized and associated with adverse outcomes. The Kidney Diseases: Improving Global Outcomes (KDIGO) work-group released best practice guidelines in 2012 for the diagnosis and management of AKI, however, the care of post-surgical patients is typically provided by non-nephrologists. At present, the incidence and severity of post-operative AKI, and the attitudes and proficiency towards AKI of non-nephrology care providers has not been explored at the University of Alberta Hospital in Edmonton, Alberta. METHODS: Chart audit was performed on all patients admitted under general surgery units 3E2 and 3E4 (excluding the Acute Care and Emergency Surgery service) from March 8 – March 22 / 2017. Charts were assessed for the following: age, sex, medical comorbidities, type and nature of surgery performed, post-operative monitoring of urine output and serum creatinine, incidence and severity of post-operative AKI, and involvement of medical or critical care consultant. Nurses on these units also completed a 14-question survey exploring their clinical backgrounds, knowledge, and perceptions of AKI. The current post-operative care pathway was then process mapped at a stakeholders meeting consisting of Unit clerks, Nurses, Unit managers, Pharmacy, and Medical team members. Along with conducting other quality methods to identify areas of improvement. RESULTS: Chart audit was completed on 32 inpatients. Mean age was 61±18 years with 47% of patients female. 31 patients (97%) experienced post-operative monitoring of renal function in the form of serum creatinine or measurement of urine output. 2 patients (6%) met criteria for post-operative AKI, with both cases representing stage 1/3 severity as per KDIGO definitions. 22 nurses completed the allied health survey, with 8 (36%) having worked in emergency, critical care, or medical units. All nurses were checking urine output, and 20 (91%) nurses were neutral, agreed, or strongly agreed that the diagnosis of post-operative AKI is a physician responsibility. Results of stakeholder’s current process meeting recognized nursing communication with physicians and ability to alert them of both clinical and paraclinical changes as the main area of opportunity. As such, a plan-do-study-act (PDSA) cycle consisting of a paper based AKI alerting system and AKI algorithm was designed and planned for implementation in Nov 2017. CONCLUSIONS: Identification that the nursing care team plays a vital role in recognition, response and referral of the AKI process has informed the planned interventions. Education that includes the use of an AKI algorithm supports recognition, response and timely nephrology consultation. Along with incorporating the AKI algorithm into the upcoming electronic medical record.

“When I saw this machine my heart sank and my mind filled with worry about how my life was about to change” When patients come to hospital for their surgery, the last thing they expect is that they are going to require dialysis. Post-operative acute kidney injury (AKI) is a relatively common complication following surgery, especially vascular, cardiac, and hepatobiliary surgery. Sometimes, kidney injury is severe enough to require dialysis – often temporary, but occasionally indefinitely, a condition known as endstage renal disease. Through improved post-operative monitoring and enhanced pre-operative risk prediction, our goal is to reduce the burden of post-operative AKI, and allow patients to go home sooner post-operatively – without ever encountering a Dialysis Machine.

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Misericordia Community Hospital - Improving Discharge Communication Changing Our Approach to Discharge Summaries AUTHOR NAMES: M. Gill, P. Mathura, L. Chan, M. Golbabaei, M. Rezaeeaval and M. Park SPONSOR NAME(S): A. Morins and N. Kassam INTRODUCTION: Discharge summaries are a standard communication tool delivering important clinical information from inpatient to ambulatory care providers. At our site, a discharge summary form is completed on inpatients, and faxed to ambulatory providers on the day of discharge. This arrives in advance of a formal, dictated discharge summary, which can take anywhere from 2-6 weeks to reach ambulatory care providers. As such, poor quality discharge forms lead to increased adverse events in patient care after discharge, the need for re-hospitalization, and disrupts care continuity. A complete, accurate, and timely discharge summary form can communicate important information to the family physician and prevent adverse events. Residents, medical students and nurse practitioners are highly involved in completing inpatient discharge documentation (titled “Uncomplicated discharge form”), yet they receive minimal training in how to do so. The project aim is to introduce formal instruction regarding form completion to improve legibility and completeness. METHODS: To define the problem and build understanding of the current process, a systematic quality improvement (QI) approach was used. QI method utilizes tools such as the 5 Whys, cause and effect analysis, force field analysis and process mapping to identify areas of improvement. To determine baseline measurement, a chart audit of the discharge summary form, a survey of clinical teaching unit (CTU) team members (residents, medical students, nurse practitioners), and a family physician survey was completed pre and post intervention. The CTU team was given a power point presentation along with a completed form- job aide focusing on the importance of filling out the forms in an acceptable way. This included a focus on legibility and clearly outlining the follow up plan. RESULTS: The number of discharge forms filled out acceptably increased from 55% pre-intervention, to 89% post intervention. Specifically, the number of forms missing information decreased from 69% to 37%, the number of forms with clear follow up increased from 65% to 89%, and the number of forms that outlined who was responsible for the follow up increased from 52% to 84%. The family physician survey reinforced that better communication about a patient’s hospitalization is required, and that the uncomplicated short stay discharge form plays a critical role between acute care physicians and family physicians. Many care providers indicated that the form needs to be updated, but if the approach to how to complete the form does not change, the results will be the same – an updated form would not be used effectively to communicate the pertinent details required. CONCLUSIONS: Discharge summary forms are a vital communication bridge between the hospital and a patient’s outpatient care team. Education on how to complete this form, and how to optimize its completion results in better patient care and helps minimize gaps in continuity of care. Awareness of the form’s importance for communication strengthened the care team’s willingness to improve and sustain discharge communication practices.

“I was given a pile of papers when I left the hospital and I put them somewhere?” Hospitalization can be a confusing time for patients and it is our job as health care providers to help them through this difficult time. At times, patients, particularly those who are elderly or have complex medical problems, are not aware of all the details of their hospitalization, and can be overwhelmed with information. As such, important details such as discharge instructions are not retained, or are remembered incorrectly. The uncomplicated short stay discharge summary forms are a vital communication tool. This form is completed on the day of discharge and faxed to a patient’s family physician. If this form is illegible, or is missing information, it can cause further confusion, or even harm a patient if an item that needed to be followed up on is missing or unclear. “I know my patient was in the hospital but now what?” We want to remove the discharge communication scramble and to ensure the follow up plan is clearly stated to strengthen the transition of care to their family physician.

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Kaye Edmonton Rheumatology Clinic Pre-visit Planning to Improve Patient Preparedness for Clinic Visits AUTHOR NAMES: X. Sun, P. Mathura, K. Binns, J. Roberts, T. Leder, F. Nunez, S. Rovensky and E. Yacyshyn SPONSOR NAME(S): S. Larson and M. Melia INTRODUCTION: Majority of patients seen in an outpatient rheumatology clinic require complex care including the need for numerous medications, regular lab work and frequent visits with their primary care physician as well as other specialists. Pre-visit planning has been proposed as a key strategy for improving compliance in other chronic disorders using techniques such as pre-visit phone calls, e-journals, pre-visit questionnaires and checklists. None of these have been studied in the context of an outpatient rheumatology clinic, but may serve to improve patient preparedness, communication, clinic efficiency and ultimately outcomes in our specific patient population. METHODS: A patient touch point map was drawn to determine the main process steps through the viewpoint of the patient. A survey of 120 patients was carried out in the Rheumatology Clinic to consider the patient perspective of the efficacy of current methods used for pre-visit planning: the booking phone call, mailed appointment package, and the www.albertarheumatology website. Results of the baseline survey were used to develop interventions to improve pre-visit planning: booking call using a standardized script, appointment package updated in a patient-friendly format with important information centered and bolded, posters placed in the front clinic reception area and nursing rooms to remind patients of ways to prepare for appointments. These interventions were trialed with 10 patients, their preparedness was evaluated by their rheumatologist, and a post-intervention survey was carried out to collect patient feedback on the improvement interventions. RESULTS: Amongst the 10 patients, 5 were first time and 5 were follow-up appointments. Appointment duration was reduced by 5 minutes for new patients and 2 minutes for follow-up patients. Through a telephone survey, the patients also reported feeling more prepared (knew what to bring to and what to expect during clinic appointments). Clinic nurses and physicians reported patient assessments were more efficient, less time was spent looking up past medical history and medications. Increasing the productivity of the clinic appointment and supporting a patient-directed discussion positively impacting the Rheumatology care plan and patient experience. CONCLUSIONS: Process changes demonstrated the importance of the patientâ&#x20AC;&#x2122;s perspective in quality improvement through consistent communication to our patients to increase their preparedness, we were able to reduce clinic cycle time, as well as increase patient and healthcare provider satisfaction.

“Combating an illness is an important part of my life, but it’s not all of my life” Stated by a patient of the Rheumatology clinic. All our patients have a simple wish: since they made an appointment, set aside a specific amount of time from their busy lives to be here for their appointment, they hope to have all the necessary assessments and interventions done in that time such that they can return to their lives. Some of our patients are retired, many others are taking time off work to come for an appointment. Some of our patients are pregnant, some bring their kids along, and others have young children waiting at home. Some of our patients are from Edmonton, many others are coming from other cities in Alberta. As healthcare providers, we understand that the appointment at the clinic is only one part of our patients’ lives. With pre-visit planning, with combined efforts from both our patients and the clinic staff, we strive to make each appointment efficient and a valuable patient experience. Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 27

Kaye Edmonton Clinic â&#x20AC;&#x201C; Dermatology Promoting adherence and advocacy for patients with glove-induced allergic contact hand dermatitis AUTHOR NAMES:

A Smylie, P Mathura, S Straube, J Elliott, C Salguero, and M Dytoc

SPONSOR NAME(S):

S. Larson, M. Melia and priMED Medical Products Inc.

INTRODUCTION:

Allergic contact dermatitis is a common occupational skin disease, which has significant associated costs and impact on patient quality of life. In healthcare workers, it is commonly seen in association with the use of medical exam gloves due to the presence of rubber accelerators. Allergen avoidance, following identification via patch testing, is the mainstay of allergic contact dermatitis treatment and prevention. However, patients diagnosed with allergic contact hand dermatitis (ACHD) to rubber accelerators face barriers to eliminating glove-related allergens. Often there is a lack of appropriate gloves in the workplace and a lack of an understanding of the need for allergen-free gloves. This may negatively impact patientsâ&#x20AC;&#x2122; symptoms, quality of life, functionality, and work ability, resulting in a significant personal and health system burden. Currently, no structured approach exists for dermatologists to promote adherence and advocate for the use of appropriate gloves in patients with ACHD. In addition, an estimated majority of patients do not return for Dermatology follow-up after patch testing. We aim to have 95% of patients follow up after patch testing and provide patients with a structured approach to promote adherence.

METHODS:

Using quality improvement methodology, a current-state review of the dermatology process identified both process- and patient- focused opportunities. Patients diagnosed with ACHD attributed to gloves and patch-tested positive to rubber accelerants (thiurams, carbamates and mercaptobenzothiazole) are included in this study. After obtaining informed consent, patients are assessed at baseline and at one month. At baseline, patients are supplied with allergen-free gloves and general care instructions. To monitor patientsâ&#x20AC;&#x2122; responses to intervention, the hand eczema severity index (HECSI; minimum 0; maximum severity score 360), dermatology quality of life index (DLQI; minimum 0; maximum severity score 30) and photographs are acquired at each visit.

RESULTS:

To facilitate patient follow-up in our ACHD-specific clinic, we developed a unique follow-up form which was made readily available to all dermatologists in their clinic rooms. Preliminary results have been obtained with two patients having completed the one-month follow-up stage and two additional patients having completed the baseline stage, at the time of reporting. A need for patient follow-up with a dermatologist was identified at baseline assessment: patient one - HECSI 8, DLQI 4; patient two HECSI 55, DLQI 18; patient three HECSI 48, DLQI 25; patient four HECSI 140, DLQI 16. At one-month follow-up, two patients demonstrated an overall improvement in their disease severity: patient one HECSI 0.3, DLQI 5; patient two HECSI 15, DLQI 12. Subjectively, patients one and two both reported a significant clearing of their ACHD with use of the gloves provided and this is corroborated by obtained photographs. An algorithm was developed to aid dermatologists in selecting appropriate gloves for their patients, post patch testing, found to have ACHD secondary to rubber accelerators. This algorithm was used to select appropriate gloves for our patients at baseline assessment. To help patients advocate for their need for allergen-free gloves, we designed a standard letter template which can be efficiently filled in and signed by their dermatologist. Patients are then provided with this letter which they may present to their employer.

CONCLUSIONS:

Our study is still in the preliminary stages of implementation, but early results have demonstrated that improved follow-up and provision of a structured approach to manage glove-induced allergic contact hand dermatitis may lead to an improvement in disease severity and quality of life. Our follow-up forms have been successfully used to easily refer patients to our ACHD-specific clinic post-patch-testing. At baseline, all patients assessed demonstrated incomplete control of their ACHD, as shown by their elevated HECSI and DLQI scores, indicating a need for patient follow-up with a dermatologist. Two patients have shown improvement in their disease severity at one-month follow-up, as shown by their improved HECSI scores. Our algorithm aided our selection of gloves in an efficient manner, avoiding the need for multi-glove trials, thereby promoting allergen avoidance and disease management.

Many patients suffer from glove allergies but their occupation requires them to wear gloves. This condition is referred to as acute contact dermatitis (ACD). Our hands are critical to all that we do as human beings. When one’s hands are sore, itchy, and rash-filled, this affects both one’s occupation and personal life, making simple tasks difficult to do. Dermatologist- “Having a way to support our patients live without eczema on their hands so that they can enjoy life and a career is why this project is near and dear to me.” ACD accounts for approximately 20% of occupational contact dermatitis. Identifying gloves that are free of particular allergens can be challenging as different types of gloves, and different brands of gloves, differ in their accelerator content. Supporting these patients with gloves and educating their occupation of what gloves to use can be life-changing for these patients. When this patient left the clinic he shook my hand!

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Royal Alexandra Hospital / Lois Hole Hospital: Reducing Excessive Laboratory Ordering for Preeclampsia: Be HIP, Gone with PIH AUTHOR NAMES: X. Thompson, W. Sia, P. Mathura, A. Wong SPONSOR NAME(S): W. Sia and J. Clink INTRODUCTION: Excess bloodwork has been noted in the investigation and management of hypertensive disorders of pregnancy. In the past, a set of bloodwork has been coined “PIH” (pregnancy induced hypertension) labs, components of which include CBC, ALT, AST, creatinine, uric acid, fibrinogen, INR, PTT, D-dimer, electrolytes, and urea. Some of these tests have not been shown to be cost-effective or useful for clinical decision-making. The goal of this project is to create a cultural shift towards mindful laboratory ordering, improve patient experience, and demonstrate cost-savings. METHODS: Data regarding laboratory testing was obtained from Edmonton Zone Laboratory Services. Information was collected regarding the number of “PIH” lab tests ordered over the span of four months, along with a care provider survey; this was used to inform interventions to reduce inappropriate lab ordering. Quality improvement methods such as process mapping, conducting a Gemba walk, and a cause and effect analysis assisted in the identification of current process strengths and opportunities. Interventions included the development of a standard ordering algorithm for hypertensive disorders of pregnancy, along with educating care providers about lab testing costs. Plan do study act cycles were used to assess the interventions. RESULTS: Throughout the initial PDSA cycle clinicians demonstrated enthusiasm and engagement in using lab tests more effectively. Laboratory testing has been observed to be decreasing during ward rounds but formal laboratory use data will be available 6 weeks after completion of the first PDSA cycle. It is anticipated that by removing AST, urea, electrolytes, and D-dimer from the investigation algorithm, the laboratory cost savings would be approximately $5216 per month. Furthermore, if a conservative estimate of 20% of pregnant women presenting with suspected preeclampsia are investigated with the use of the basic preeclampsia panel or the preeclampsia screening panel, with the remainder receiving the severe preeclampsia investigation panel, the anticipated cost reduction would be an additional $741 per month. CONCLUSIONS: A standard ordering algorithm for hypertensive disorders in pregnancy in conjunction with ongoing education regarding test utility and costs has led to excellent clinician engagement in optimizing and streamlining laboratory test usage for preeclampsia at the Royal Alexandra Hospital. Anticipated conservative cost savings for laboratory testing is $5957 per month, and the algorithm is also anticipated to significantly reduce patients’ blood loss from repeated phlebotomy.

I remember the look of cold fear when we have to tell expectant mothers that they have pre-eclampsia. Immediately, they ask, “Will my baby be alright?”, and we tell her what we always do: “We’ll do our best.” What I’ve noticed is that our patients always have trouble sleeping, and when I ask why, they often tell me their fears about the future are keeping them up. “I’m thinking about all the complications,” one mom said to me. “Strokes, liver problems, fluid in the lungs…but what really worries me is not my own risk of complications, but my baby’s. Every minute, I’m scared I’ll be told that my baby needs to be delivered prematurely through C-section.” In the rare moments that my patients do get to sleep, we frequently wake them by the prick of a needle, where we then proceed to fill vials and vials of blood for testing. Like clockwork, we draw their blood, sometimes three or four times a day. It makes we wonder whether this is really necessary, as I am reminded of the realities of hospital care and how our care plans can impact mothers-to-be.

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High-users of Acute Care: A Deeper Dive into Predictive Patient and System Factors AUTHOR NAMES: A. Gantayet, A. Fong, P. Mathura, F. McAlister and N. Kassam SPONSOR NAME(S): N. McMurtry, C. Osborne, D. Taylor INTRODUCTION: The unsustainability of current healthcare costs and challenges of a complex and aging population have made it increasingly important to improve efficiency and efficacy in healthcare delivery. It has been observed in various settings that a small proportion of the population makes up for a large quota of health care utilization. In Alberta, 5% of the population accounts for 66% of healthcare use and costs. It is estimated that 9-59% of readmissions are preventable. Local projects such as the IHI Triple Aim collaboration targeting patients with chronic, complex and long-term care needs have shown positive outcomes while reducing costs (CFHI, 2015). METHODS: The overall aim of this project is to reduce readmission rates in Internal Medicine patients by using a patient-centered approach. Our objective is to study high-cost users of acute care, identify targetable factors and design one or more quality improvement interventions to target modifiable factors. High-cost users (CIHI definition) include patients with at least three admissions and a cumulative length of stay of greater than 30 days. We identified 167 ‘high-user’ patients at the University of Alberta Hospital (UAH) with three or more admissions from Sept 2015-16 using DiMR data. Only 124 of these high-users met the High-Cost User (HCU) definition and subsequently underwent chart review to analyze patient characteristics including social profile, community supports and comorbidities. The results reported are based on very preliminary analysis. RESULTS: Demographic analysis shows that males (56%) and patients between 60-80 years (40%) have more re-admissions to the UAH. Younger high-users (<40 years) have fewer re-admissions and are more likely to seek acute care through ED visits and admissions at other hospitals. Higher number of admissions and higher cumulative Length of Stay do not directly correlate with high-user characteristics. General Internal Medicine (GIM) accounts for 31% of high-user re-admissions, followed by surgical specialties (26%), GI (16%) and Hematology (15%). The social profile of HCUs emphasized the importance of community supports; 50% were dependent for ADLs, over 50% received home care, 10% lived in long-term care, 8% in supportive living and 5% had no fixed address. 89% appropriately reported a GP as their primary care contact. Chart reviews identified prominent comorbidities in HCUs and found that 77% of HCUs were prescribed ≥7 discharge medications. The LACE score was a better predictor of HCUs than the Charlson Comorbidity Score. CONCLUSIONS: A unique interplay of patient and system factors influences re-admissions in high-users based on preliminary analysis of the UAH chart review. Next steps include a survey of identified HCU family physicians to assess how often primary care resources are accessed. The medical and social profile of these patients will be used to identify characteristics predictive of high-users. We will subsequently design QI projects to target modifiable factors including community resource integration, transitions and medication reconciliation. The goal of this project is to decrease re-admission rates in High-Cost Users at the UAH by 30% by December 2018. 32

Your pillars of support are what you need, Your faith, your determination, the loved ones you heed, Your pillars will lead you through the darkness of the tunnel, Guiding towards the light, filtering the past through a funnel. And when you learn once again to hold your ground, You will rise like the phoenix, from your ashes, rebound, Stronger, wiser, more beautiful than ever before, The wisdom of the past shining brightly through your core. Â Then thankful you will be for the lessons past learned, Appreciation you will reap for the moments now returned, Your pillars now engraved more deeply into lifeâ&#x20AC;&#x2122;s pattern. We hope that characterizing the medical and social profile of these patients will enable development of targeted interventions that will help reduce preventable re-admissions. Repeated visits to the emergency department are a huge burden to patients and their families. They suffer not only from the distress of their illness but also the frustration of not being adequately managed and the anxiety of having to return repeatedly to the hospital. Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 33

Edmonton Zone, Department of Medicine Access Partnership Project (APP) AUTHOR NAMES: N. Kassam, N. McMurtry, P. Mathura, S. Marini and H. Choi SPONSOR NAME(S): B. Ballermann and N. McMurtry INTRODUCTION: The Edmonton Zone Medicine Strategic Clinical Improvement Committee (SCIC) was formed as a collaboration between the Department of Medicine (DoM) and Alberta Health Services (AHS) Medicine Operations as a Medicine EZ Quality Council. One of the major priorities of the SCIC is to work toward optimizing referral access and central triaging for patients and care providers in order to improve care delivery. The foundation for this work is built on the AHS Level 1 policy â&#x20AC;&#x201C; Wait Time Measurement, Management and Reporting of Scheduled Health Services. This policy was approved September 3, 2013. Linking with the AHS Path to Care department facilitates scheduled services in defining and building understanding around their specific opportunities for access management. METHODS: Project was segmented into 5 phases. The first three phases are underway. Phase 1 involved the development of draft referral guidelines for 12 sub-specialties that will be uploaded into the Alberta Referral Directory (ARD) and have further links to the appropriate physician profiles. Assisting other specialists and primary care physicians clarify what information is required on a referral to support standardization of access for patients, increase communication to the referring healthcare provider and decrease the number of incomplete and inappropriate referrals. Phase 2, and 3 incorporated the use of quality improvement methodology to develop and analyze the current referral processes, close gaps, develop a future state process and develop a referral source engagement strategy. The aforementioned supported the development of an action plan and streamlined referral measurement to reflect similar operational processes within all divisions of the DoM. Also, develop an engagement strategy with the referral sources with improvement opportunities co-designed collaboratively. RESULTS: 12 of 12 divisions have completed a current state analysis which identified one future state referral process informing the development of 65 of standard operating procedures that incorporate the existing IT scheduling system and salient referral management measurements. The baseline access assessment tool (AAT) average score for the 12 divisions was 57.8% this is 0.8% higher than the Alberta provincial average score. The AAT score will be repeated in Dec 2017 to determine the trend to towards compliance with College of Physicians and Surgeons of Alberta, Path to Care and the AHS Wait Times Policy. 100% of divisions have submitted completed referral guidelines with access targets updated to the ARD. CONCLUSIONS: Referral management standardization for the 12 Divisions within the DoM; referral guidelines that support the referring sources and establishment of a common referral process can be achieved. Continual effort is underway to maintain project focus. Standardized referral processes identified require further refinements and integration with the new clinical information system to be completed within each individual division prior to the development of a DoM centralized access and triage referral process which is the ultimate Phase 5 goal.

Everyday, many patients in the Edmonton Zone need to see a specialist. Sometimes their family doctor may not be aware of what information is required for them to be seen causing the patient to have to wait. Family physicians may not be aware of which specialist is best to care for their patient’s specific needs. The Alberta Referral Directory (ARD) is an online database that helps family doctors find the right specialist for their patient and supports them with referral guidelines to ensure they send all the right information so that the patient can be seen in a timely manner. In our current paper based system, management of the incoming referrals means that the actual paper referral is moved through many hands; every hand performing a specific task so that patients receive a timely appointment and get the care that they need. A consistent referral process is critical to ensure patients do not fall through the referral process cracks. Admin Staff - “By dealing with referrals and patient waits in a consistent manner, I can eliminate a lot of the challenges faced when managing patient and provider expectations” Specialist physicians- “As a champion for consistent processes, I can make sure that every patient is receiving the appropriate care at the appropriate time” Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 35

Improving Collaboration and Access to Rehabilitation for Stroke Patients at Grey Nuns Community Hospital AUTHOR NAMES: J.C. Yu and P. Mathura SPONSOR NAME(S): L. Chivers, M. Siddiqui, N. Kassam and N. McMurtry INTRODUCTION: Access to stroke rehabilitation services varies greatly across Canada for victims of acute stroke. Within the Edmonton Zone (EZ), significant variability exists regarding access to physicians with expertise in stroke rehabilitation. Prior to July 2016, only a single physiatrist was available to provide consultation services to all acute care sites in the EZ for stroke rehabilitation assessment. Access to tertiary stroke rehabilitation at the Glenrose Hospital is dependent on this formal assessment, and thus limited by physician availability. Additional physician manpower was added in July 2016, but the process for initiating a formal assessment remained variable and inconsistent. A need was identified to review the criteria and process for initiating assessment by a physiatrist, and to reduce the variability of consult requests and timing in order to improve patient access to tertiary rehabilitation services. METHODS: The quality intervention that was initiated for this project was to change the consultant physiatrist model from reactively attending consultation requests as they came in, to proactively attending regularly scheduled Stroke Unit rapid rounds on a weekly basis regardless of consults pending. The physiatrist thus became an arms-length regular member of the Grey Nuns Acute Stroke interprofessional team. Nursing and allied health staff were surveyed at 1-month post intervention, and asked to provide reflection on the status of several qualitative measures both prior to and after the intervention. Cycle time measures were used to assess for any change in times to rehabilitation assessment or time to transfer to tertiary rehabilitation. RESULTS: The staff survey yielded a 70% response rate. The most significant finding was a significant increase (43% pre, 86% post) in staff confidence in discussing stroke prognosis and recovery with patients and families. Staff perception of timeliness of assessment for stroke rehabilitation also increased from 29% agreeing this was timely, to 71%. This change in perception occurred despite no objective change in median time from consultation request to assessment by physiatry (2.5 days pre, 2.0 days post). Preliminary data did not demonstrate significant impact on median time from stroke admission to transfer to tertiary rehabilitation at the Glenrose Hospital. CONCLUSIONS: Despite no major changes in the cycle time measures for time to consult and time to transfer, significant improvements were noted in the Acute Stroke Unit team perception of the timeliness of rehabilitation assessments by physiatry and in the confidence of the team members for discussing the stroke prognosis and recovery with patients and families. Such changes in team perceptions cannot be understated, as they have led to improved morale and a stronger sense of collaboration between acute care and tertiary rehabilitation

Acute stroke is one of the leading causes of adult onset disability, and can have a devastating impact to patients and families with major changes to how an individual is able to perform their daily activities and to their sense of independence and self. Management of acute stroke and stroke recovery requires a dedicated and collaborative team approach. From the moment a patient enters the emergency department, until the day they are ready to be discharged home, multiple interprofessional teams are involved in the care of the patient, and highly functioning teams can have a significant influence on the patient and family experience as well as the ultimate stroke recovery outcomes. The Grey Nuns Community Hospital has a well organized Acute Stroke Unit, with a great team of nurses, physical therapists, occupational therapists, speech language pathologists, social workers, transition coordinators, pharmacists, unit clerks, nurse practitioners, neurologists, and (newly) a physiatrist â&#x20AC;&#x201C; all providing evidence-based and high quality care for stroke victims. This team provides an amazing example of truly interprofessional collaboration, with respectful discussions, shared decision making, and always keeping the patient and family at the forefront.

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University of Alberta Hospital Admission Protocol Impact on Emergency Department and Patient Flow AUTHOR NAMES: N. Kassam, X. Sun, J. Keegan, D. Sinclair, P. Mathura, J. Zhang, and B. Sevcik SPONSOR NAME(S): C Osborne and D. Taylor INTRODUCTION: In November 2007, a decade ago, the University of Alberta Hospital (UAH) Emergency Department (ED) Admission Protocol was developed using wide-spread consultation among the Medical and Surgical section leads and adopted by the UAH Site Medical Leadership. In addition to providing general guiding principles for consultation in the ED, it also provides specific guidelines for which medical service should be responsible for admitting what type of patients based on their diagnostic presentation and the resources that were available to those services at the time of presentation. A focus group held in March 2017 revealed underutilization of the Admission Protocol by ED physicians, and at times inappropriate or multiple services (defined as not meeting the guidelines of the Admission Protocol) being consulted leading to delays in admission, ED overcrowding and hospital wide patient flow issues. At the UAH, at least 15% of admissions occur after two or more consults and the average time from consult request to admission decision is 4.5 hours. With the above issues evident, our project aims to increase utilization of the Admission Protocol by ED physicians as well as decrease inappropriate and multiple consultations prior to decision to admit. METHODS: Two patient focus groups were held in March 2017, one among ED physicians to determine usage of the Admission Protocol, the other was held with ED physicians, General Internal Medicine (GIM) physicians and senior Internal Medicine residents to discuss their thoughts about the ED service consultation and admission process. Next, a chart audit was carried out to determine if the consulting and admitting services were appropriate according to the existing 2007 Admission Protocol. An analysis of the 9 main services with admitting privileges (Family Medicine, GIM, Cardiology, Gastroenterology, Nephrology, Neurology, Pulmonary, Hematology and Geriatrics) yielded 10166 Medical admissions in 2016. 31% (3175 patients) were identified as having multiple consults and a random sample of 222 multi-consult patients was selected for chart audit. A quality methodology-Gemba was conducted to determine the high level processes under review to assist with identifying areas of opportunity. RESULTS: Focus groups revealed that although 100% of ED physicians are aware of existence of the Admission Protocol, 82% used it only “sometimes”. Infrequent use was as a result of outdated protocol, pushback among consult services, lack of site enforcement, lack of understanding, and the reality that some patients are better suited for services not covered in the Protocol. There was also a dissatisfaction among GIM physicians and residents about GIM becoming the “default service” for patients with medical illnesses regardless of diagnosis and consideration of site bed allocation when another alternate service could have provided appropriate care. The chart audit showed that 18.3% of patients could have been admitted to an alternate service using the 2007 Admission Protocol, and majority of the consults (53% and 16%) occurred during evening and overnight shifts respectively. The data also indicated that for each additional consult made, there was an average of two hours delay for patient admission, and the majority of patients requiring multiple consults were admitted to GIM. CONCLUSIONS: The pre-intervention analyses of the consulting and admitting process in the ED helped identify opportunities for improvement. In the next 3 months, the following will be undertaken: updating and approval of the Admission Protocol by involved stakeholders, develop job aides to increase its use by ED physicians and conduct PDSA cycles with a focus on reducing multiple consults, increasing appropriate service consults the first time, minimizing evening and overnight shift consult requests to decrease stress on staff, and in turn reduce cycle time from first service consulted to patient admission promoting efficient patient care and flow in the ED. 38

“My journey in the ER is so complex and one filled with many medical care teams. I just spoke with the third medical team? Why do I need all of these teams to examine me? Is the care I need so complex? What is going on? This worries me” Making every patient step in the Emergency Department (ER) matter is one reason why the Admission protocol was developed. This protocol assists the ER physicians in determining the most appropriate medical services to consult the first time to support the patient’s medical needs. Sometimes there are delays - similar services may be consulted or a patient may present with vague or unclear symptoms. It can be difficult to determine which medical service is required and is the best medical team to take care of the patient’s medical issues. Our goal is to update the Admission protocol such that it is clear, transparent and user-friendly for physicians at the point of care in the ER. This will allow efficient consultation of appropriate services to assess patients, and allow patients to be admitted to the most suitable service. Ultimately, we hope to minimize the patient’s stay in the ER and in the hospital and to be discharged home as soon as possible.

Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 39

Glenrose Rehabilitation Hospital (GRH)-Deprescribing Benzodiazepines: A Quality Improvement Initiative AUTHOR NAMES: F. Carr, P. Tian, J. Chow, J. Guzak, J. Triscott, P. Mathura, X. Sun and B. Dobbs SPONSOR NAME(S): H. Kammerer and A. Bertagnolli-Hansen INTRODUCTION: Benzodiazepines are classified as psychoactive drugs commonly used in the treatment of anxiety, insomnia and seizures. Despite the high rates of associated side effects in seniors, benzodiazepine prescriptions in this population are common, and often prescribed inappropriately. In light of this issue, there has been a growing interest in the ‘deprescribing’ of benzodiazepines. Although the process of deprescribing of benzodiazepines is usually performed over an extended period of time, commonly in the community, the process can be initiated in hospital and continue post discharge into the community with lasting effects. There are currently no single provincial or nationally recognized standard or strategy towards benzodiazepine deprescribing; instead, current practice is usually dictated by the individual, provider and the situation. METHODS: A Gemba walk was conducted to determine the current unit process, and a high level (SIPOC) process map was developed. Baseline data was collected in unit 4C at the Glenrose Rehabilitation Hospital (GRH) regarding current benzodiazepine deprescribing status. A 4-step change intervention was initiated from August to October 2017 that included a structured medication review, patient education using the EMPOWER brochure, patient counselling and relay of deprescribing information to community healthcare providers to allow continuity of care. Deprescribing status in unit 4C is then re-evaluated post-intervention RESULTS: Due to a small number of patients admitted with active benzodiazepine prescriptions in unit 4C, the study was expanded to include unit 3D at GRH. Among the two units, 5 patients were recruited and offered the 4-step change intervention. At time of discharge, 2 patients had their benzodiazepine prescriptions discontinued, and 1 had her dose reduced with plan to continue the deprescribing process in the community. The other 2 patients have just started on the intervention and deprescribing has not been initiated yet. The physicians on the unit reported being more aware of appropriate indications for benzodiazepines in the elderly population, and more confident in the deprescribing process. The patient provided feedback in that they like the EMPOWER booklet, and appreciated the slow personalized tapering that reduced withdrawal effects. CONCLUSIONS: Through this short quality improvement initiative, our goal was to educate the prescribers and “consumers” of benzodiazepines. With increased awareness on appropriate indications and harms of long-term benzodiazepine use, the use of tools to assist shared decision making between physicians and patients has the potential to allow for safe and personalized deprescribing of this class of psychoactive drug. This will in turn reduce the incidence of geriatric syndromes such as falls and delirium and improve health outcomes as well as quality of life of our patients.

Insomnia is one of the common reasons our elderly patients take benzodiazepines. However, there are other more suitable alternatives for insomnia such as sleep hygiene and melatonin. Benzodiazepine use in elderly people can increase falls. For these reasons, there is a need to increase awareness of our patients on benzodiazepines. It is a class of medications with serious negative reactions, and a patient should have it deprescribed if they have no medical reasons to be taking this drug, wrong indications or when there are better alternatives for the indication. This is why we decided to start this quality improvement initiative: it is to take our patients who do not need benzodiazepines off its dependence, and at the same time maintain an optimal quality of life. As a team we have to work with patients to help them through change. An initial reaction might be: â&#x20AC;&#x153;Cut down on my benzodiazepine? No, you cannot take it away from me, I cannot sleep without it!â&#x20AC;? This project helps support patients to reduce benzodiazepine use in a patient focused way. Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 41

Mealtime Companionship Program at the University of Alberta Hospital: a study on the views of patients, volunteers, health care providers, and relevant stakeholders AUTHOR NAMES: D.H. Lee, P. Mathura and N. McMurtry SPONSOR NAME(S): N. McMurtry, N. Veronovici and F Robinson INTRODUCTION: The Project Team evaluated the Mealtime Companionship Pilot Program in two orthopedics department at the University of Alberta Hospital (UAH). Using various quality improvement (QI) methodologies, we described the strengths of Mealtime Companionship Program, identified any concerns surrounding the new initiative, and suggest how these problems will be resolved through improvements and expansion of the companionship service in the future METHODS: Through walking the Gemba, gathering the Voice of Customer, and developing a Process Map, several areas for improvements were identified. All data were further processed through SWOT analysis, which allowed the QI team to focus on three areas of improvement: the use of communication binder, the environment of the dining area, and the expansion of the companionship program to include a volunteer led feeding service. A photovoice poster was developed to capture the impact that the program is making at the patient-care level. This poster was displayed on the unit to inspire and motivate all unit staff to manage positive changes to further improve the Mealtime Companionship Program. RESULTS: The challenges mentioned above were resolved through a team collaboration between the Project Lead, a QI Consultant, UAH Operational Leader, Unit Managers, Director of Director Nutritional Services, and the Coordinator for the Volunteer Resource Centre. The Director Nutritional Services highlighted the importance of regular review and sign off of the communication binder with dietitians involved on the units. The checked off rate has increased from 7.5% to 79% post intervention in the orthopedic units. Unit managers, frontline staff, and volunteers were all involved in improving the environment of dining area, which now provides a more inviting atmosphere. The QI team plans to form a committee composed of relevant stakeholders to expand the Volunteers role to include a feeding services to the program. CONCLUSIONS: Both care providers and patients enjoy participating in the newly improved Mealtime Companionship Program. With an efficient reallocation of available resources and the nurturing of a supportive team atmosphere, the Mealtime Companionship Pilot Program successfully deliverers family-centered care to patients staying in the orthopedic units at the UAH.

“Connecting with a patient is the most rewarding aspect of being involved with the Mealtime Companionship experience”. As volunteers, we know patients by their name and by the stories they share with us. We learn that a patient likes vanilla rice pudding but will never eat chocolate pudding. We learn how much ketchup a patient wants to put on mashed potatoes. We see a patient’s excitement when a family member comes to visit. We marvel at how a patient admires and loves her husband, who has worked as a firefighter for 50 years. As volunteers, we meet families from many places such as a family member visiting from Lloydminster, Saskatchewan. We smile as a patient reminisces about teaching a student, who became a medical doctor and said, “you can come to me for your health, anytime, free of cost.” Through conversations and time spent together, patients and volunteers become friends. Volunteers provide care that comes from unconditional support. Together, patients and volunteers celebrate and share life experiences over the mealtime. Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 43

The EPIQ workshop: simulation-based quality improvement learning for clinical teams AUTHOR NAMES: K. Aziz, S. Shivananda and N. Singhal SPONSOR NAME(S): University of Alberta Department of Pediatrics, University of British Columbia, University of Calgary INTRODUCTION: Health care providers and administrators are often overwhelmed by the number and complexity of quality improvement (QI) interventions, tools and methodologies. The Evidence-based Practice for Improving Quality (EPIQ) training workshop has been a key component of 4 multicentre clinical studies in Canada since 2002, all demonstrating improvements in morbidities in Canadian neonatal intensive care units. Following these successes, the EPIQ workshop was re-engineered to demystify QI planning for health care teams, so they can design, execute, and share QI projects METHODS: Early EPIQ course agendas were deconstructed and reassembled into 10 logical steps. Literature searches (PubMed and Omnifile) identified evidence-based tools. A social constructivist educational design gave each step a brief, a simulated exercise, and time to reflect and share. The result was a collaborative, team-based, interprofessional learning workshop that addressed real-life issues – so participants were able to learn from one another, and from more experienced or knowledgeable peers and facilitators. The dissemination model followed the “Utstein principle” (of the International Liaison Committee on Resuscitation): a successful educational program needs (a) good clinical science, (b) effective educational science, and (c) efficient dissemination science. By the end of a workshop, participating teams can address a real-life QI issue by outlining the principles of QI, following 10 practical steps, and completing aim and plan-do-study-act documents. RESULTS: This simulation-based workshop, designed from first principles, is relevant to post- and undergraduate learners and has been well received by health providers in Canada, Africa and Asia. Participants mostly agreed or strongly agreed that the workshop had useful content and that the delivery was effective. The workshop is being adapted for a postgraduate medical curriculum at the University of Alberta. Pilot studies are under way in urban and rural Ethiopia. CONCLUSIONS: The EPIQ workshop trains QI methods to health care providers and administrators irrespective of experience or health care system. Course participants in India, Canada and Ethiopia have perceived the workshop as both useful and effective, reinforcing the generalizability of the methodology. The EPIQ workshop will expand the reach of QI training to both post- and undergraduate learners

Quality capacity building is a key objective of the Medicine Zone Strategic Clinical Improvement Committee. This summer we were fortunate to have a group of wonderful students to work with our teams on our quality projects. “Working on quality improvement projects has allowed me to collaborate with physicians and other healthcare professionals to identify problems, develop solutions, and manage change. With the healthcare system being so complex, there are countless opportunities for innovation to improve the patient experience and how we deliver care, and I am grateful to have been able to participate in the QI process.” “Pharmacy School has inspired me to deliver family-centred care to patients and their families; Quality Improvement training has enabled me to foster an environment where we could provide such care.” "Balancing measures. Fish bone map. PDSA. These were all foreign terms to me before this summer. My experience with EPIQ has been magical thus far, it changed my past impressions of medical research and opened my eyes to new horizons. In the near future when I become a physician, I will definitely continue to embark on this journey with quality improvement in my practice as I truly believe it can improve patient outcomes and optimize patient care.“ “Working to create an opportunity for medical students to experience the quality improvement process firsthand has been a rewarding experience. I hope that by introducing quality improvement education earlier in undergraduate medical training, we can help future physicians become the best possible advocates for patient safety.” “Quality Improvement has shown to me how important the patient perspective and experience is, and how important it is to try to adequately and accurately capture the messages and experience of patients. It’s very easy to unintentionally approach QI from a paternalistic perspective, and so I think it’s important that everyone is vigilant in checking whose perspective is being presented.”

Building Organizational Capacity for Clinical Quality Improvement in an Integrated Academic and Large Health System AUTHOR NAMES: N. McMurtry, N. Kassam, and P. Mathura SPONSOR NAME(S): B. Ballerman, C. Osborne and D. Taylor INTRODUCTION: The University of Alberta (U of A) Department of Medicine (DoM) and Alberta Health Services (AHS) Zone Medicine Program had overlapping strategic priorities to develop a strong clinical quality improvement agenda and improve outcomes for medicine patients in the Edmonton Zone. As a result, the Edmonton Zone Strategic Clinical Improvement Committee (SCIC) was formed in alignment with the DoM strategic plan and the AHS quality management framework (QMF) supported by a DoM funded strategic clinical improvement consultant co-located with the administrative lead for AHS for Edmonton Zone Medicine. The primary mandate of the SCIC is to build organizational capacity for clinical quality improvement (CQI) within the DoM at the University of Alberta and within the Edmonton Zone Medicine Programs at five large sites. METHODS: An analysis of the strengths, weaknesses, opportunities and threats including an environmental scan was undertaken. This revealed key strengths and opportunities within both organizations that could be leveraged in a collaborative approach to move our joint agendas forward. The formation of the SCIC committee enabled forming key partnerships across the U of A and AHS to support the committee including, but not limited to: AHS Path to Care, Patient Engagement to support on boarding a patient advisor, U of A Post-graduate Medical Office, Life Long Learning, AHS Quality to align quality improvement education between AHS and the U of A and lastly working with the U of A to create a scholarly path for academic promotion and recognition. RESULTS: SCIC meets monthly with a 75% attendance rate of its 44 active members who are recognized as CQI leads within their divisions/sections and sites. Individual sections and site business meetings are expected to include a CQI updates from SCIC representatives. Development of AHS- EPIQ (Evidenced-based Practice of Improving Quality) accredited physician quality improvement educational stream has trained over 100 physicians, residents, students and AHS leaders. Educational workshops are planned to take place every 2 months for 2017-18. Currently, there are over 15 projects either underway, scoped or pending directly linked with SCIC. The committee has secured over $100,000 in funding to complete these projects and future grant proposals are underway. In addition, a complex (3-year) DoM CQI project related to centralized triage and referral management is ongoing with nearly 60% completion. CONCLUSIONS: This project outlines an approach to building organizational capacity for CQI within an academic department by building partnerships and engaging various stakeholders at key strategic points.

I started with the Edmonton Zone Medicine Strategic Clinical Improvement Committee (SCIC) in the spring of 2017, at the invitation of Natalie McMurtry. My first introduction to the group was at a SCIC meeting in June of 2017. I was completely captivated by the committee members who are some of the most dedicated, passionate and compassionate people I have had the pleasure to meet. I was asked to be a part of the Quality Improvement project in the Mealtime Companionship Program at the University of Alberta Hospital. This truly gave me an understanding of the scope and breadth of positive changes that are possible when outcomes are based on what is best for the patient. Working with team members Pamela Mathura and Dillon Lee was a delight. Their enthusiasm is so contagious. â&#x20AC;&#x153;Being a patient advisor is truly an opportunity that comes once in a lifetime. I hope to contribute positively to any project that I am involved withâ&#x20AC;? Being admitted to the hospital is a scary experience for patients and family members, filled with anxiety, pain and uncertainty. With our project, we hope to decrease that pain and anxiety as much as possible. Medicine Zone Strategic Clinical Improvement Committee - Partnerships in Action for Quality Care 47