2018 Quality Improvement Collaborative Day Booklet

Quality Improvement Collaborative Day

Physicians, Residents, Students & Alberta Health Services Care Providers Friday, November 16, 2018 Medicine Grand Rounds 08:00 - 09:00 a.m.

Presentations 09:15 a.m. - 12:30 p.m.

Bernard Snell Hall & Foyer

Edmonton Zone Medicine Quality Council 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 Edmonton Zone Medicine Quality Council, Strategic Clinical Improvement Committee (EZMQC-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 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 EZMQC-SCIC Senior Quality Consultant, Pamela Mathura.

The 2nd Annual University of Alberta - AHS Medicine Quality Improvement Symposium on November 16, 2018 is a celebration highlighting the accomplishments of the members and partners of the EZMQC -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, EZMQC-Strategic Clinical Improvement Committee

2

Yvonne Suranyi Co-Chair, EZMQC-Strategic Clinical Improvement Committee

Quality Improvement Collaborative Day Table of Contents About the EZMQC-SCIC

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EZMQC-SCIC Leadership

4-5

Dr. W. Ward Flemons

Professor of Medicine Cumming School of Medicine, University of Calgary

6

Department of Medicine Grand Rounds - Dean’s Lecture Series

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About the Day

7

Meeting at a Glance

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Poster Presentation Summary

8-9

Poster Scoring Criteria

10

Abstracts

11 - 35

Acknowledgements

Back Cover

Edmonton Zone Medicine Quality Council Strategic Clinical Improvement Committee Partnerships in Action

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About the EZMQC-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 Medicine Quality Council (EZMQC) – 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 AHS administrative lead for Edmonton zone Medicine.

This council working closely with both academia and frontline care providers provides the platform for strategic quality improvement interventions to be developed, tested and shared with the Edmonton zone Medicine divisions, hospital sites and community partners. Ensuring communication and collaboration as this pertains to the areas of clinical activity and clinical administration.

To serve as a resource for regular evaluation of clinical needs and priorities, initiatives and processes to build a dynamic cycle of continuous improvement in the in-patient and ambulatory patient experience.

EZMQC-SCIC Leadership

Narmin Kassam, MD, FRCPC Director, Division of General Internal Medicine Deputy Clinical Director, Department of Medicine, University of Alberta Dr. Kassam is Professor of Medicine at the University of Alberta, and Deputy Clinical Director, Department of Medicine. Her clinical practice encompasses in-patient and ambulatory consultative GIM and 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 EZMQC Strategic Clinical Improvement Committee (SCIC) that is undertaking various clinical QI initiatives in the in-patient and ambulatory settings in the Edmonton Zone. Her other major leadership roles include; co-chair of the ConnectCare Medicine area Council for the province and Medical Director of the newly formed Virtual Hospital in the Edmonton Zone.

Dr. Kassam is the current chair of the Royal Collegeof Physicians and Surgeons Canada (RCPSC) GIM Specialty Training Committee which was instrumental in advocating for recognition of GIM as a distinct discipline at the RCPSC, and develops trainign standards for GIM programs across Canada.

She is currently serving as Governor for the American College of Physicians, Alberta Chapter.

Teamwork: Coming together is a beginning Keeping together is progress 4

Working together is success!

Yvonne Suranyi, Registered Nurse Executive Director, UAH/EZ Medicine Program UAH/Stollery Emergency Yvonne is Executive Director of University of Alberta/ Stollery Emergency and the University of Alberta Hospital/EZ Medicine Programs.

As part of one of Canada’s clinical, research and teaching hospitals, her portfolio consists of approximately 244 medical beds, 8 Sleep Disorder beds, 74 Emergency beds (Adults and Pediatrics) with a range of Medical services including pulmonary, nephrology, Inpatient TB, Haematology, Geriatrics, Geriatrics Neurology, Family Medicine and General Internal medicine. She has strategic responsibility for medicine programs across the Edmonton zone.

The UAH/Stollery Emergency treats more than 140,000 patients annually. It is a quaternary, Level 1 trauma centre that serves as a major referral centre and hub for patients in the Edmonton Zone, northern Alberta (i.e., north of Red Deer), north-eastern British Columbia, north-western Saskatchewan, the Northwest Territories, and Nunavut.

Together we focus on patient flow, quality improvement and implementation of new evidenced based initiatives improving our patient, family and staff experience.

Previous to this role Yvonne has held several leadership roles in the Edmonton Zone during her 30 + years in health care delivery. Her administrative leadership contributions include quality improvement, and implementation of patient-centered care initiatives. In addition to her passion for health care, Yvonne enjoys time with her twin daughters and husband.

Pamela Mathura, MBA B.Sc. MLS Senior Strategic Clinical Improvement Consultant, SCIC Pamela is a Senior Strategic Clinical Improvement lead and a clinical lecturer for the University of Alberta Department of Medicine and Alberta Health Services-Edmonton zone Medicine. Her role as a quality lead for the Edmonton zone medicine quality council-Strategic clinical improvement committee (SCIC) includes leading quality improvement (QI) teams and QI training. She is also the preceptor for a QI elective in the faculty of pharmacy. Pamela currently is pursuing a PhD in Healthcare Quality Philosophy from Queens University.

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.

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Department of Medicine Grand Rounds in partnership with the Dean’s Lecture Series

Keynote Speaker & Guest Adjudicator (for poster presentations)

“Opportunities for an Academic Career in Quality Improvement and Patient Safety” Objectives: Describe a quality and safety management model Develop insight into a Royal College Area of Focused Competence in Quality Improvement and Patient Safety Debate the premise that academic advancement in quality improvement and patient safety be considered the fourth ‘pillar’

Dr. Flemons is a respirologist and sleep medicine specialist at the Foothills Medical Centre and a Professor of Medicine at the University of Calgary’s Cumming School of Medicine.

He has a passion for Quality Improvement and Patient Safety – he serves as a Medical Director for the Health Quality Council of Alberta and in that capacity has led and participated in several large reviews of Alberta’s health systems.

He chairs two certificate courses at the University of Calgary on Patient Safety and Quality, teaches on these topics in the undergraduate curriculum and lectures widely within the province and nationally on these issues.

Dr. W. Ward Flemons Professor of Medicine Cumming School of Medicine University of Calgary Keynote Speaker Guest Adjudicator (for poster presentation)

He was a member of the CanMEDS 2015 Patient Safety and Quality Improvement Expert Working Group for the Royal College of Physicians and Surgeons of Canada.

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Second Annual Quality Improvement Collaborative Day The second annual Department of Medicine and Alberta Health Services Collaborative day celebrates another year of Quality Improvement (QI) scholarship and collaboration between academia and frontline clinical care. This direct linkage allows learning, innovation and discovery to translate into better care and outcomes for patients, care providers and the health system.

QI learning from inception of the EZMQC-SCIC has been provided to over 500 Physician, Residents and Medical students in direct collaboration with the post graduate medical education (PGME). We are excited to announce that UA PGME is an official partner of this QI event today and as QI moves forward into the future.

Alignment to the AHS quality management framework provided wider partnerships with other AHS quality departments showcasing today QI projects led by Physicians and, Residents with support from Medical students or projects where Physicians were part of the integral QI team.

Each teams’ collaborative effort serves as a role model for championing why QI matters.

Thank you for joining our celebration and sharing your thoughts and perspectives to further enhance QI culture and innovation!

Meeting at a Glance Time

Title

Speaker/Facilitator

Location

Medicine Grand Rounds - Deans Lecture Series 08:00

Title Opening Remarks/Introduction

Dr. Barbara Ballermann

Bernard Snell Hall

08:00 - 09:00

Keynote Speaker – “Opportunities for an Academic Career in Quality Improvement and Patient Safety”

Dr. Ward Flemons

Bernard Snell Hall

Edmonton Zone Medicine Program Strategic Clinical Improvement Committee 09:00 - 09:15

Dr. Narmin Kassam & Yvonne Suranyi

Opening Remarks

Bernard Snell Hall

Oral Presentations: 09:15 - 10:00

“Implementing a New Diabetic Algorithm for Ophthalmology Day Surgery Patients at The Royal Alexandra Hospital (RAH)” “Implementing a procedural Sedation Checklist as a Quality Improvement Iniative”

Bernard Snell Hall

“Using Quality Improvement (QI) Methodology to Develop a Standardized QI Educational Curriculum for Internal Medicine Residents”

10:00– 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. Ward Flemons

Bernard Snell Hall Lower Foyer

12:00 – 12:30

Final Remarks and Poster Presentation Closing

Dr. Narmin Kassam & Yvonne Suranyi

Bernard Snell Hall Lower Foyer

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Poster Presentations

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

1

2

3

4

Project Title

Author(s) C. Collins, P. Mathura, N. Kassam, & A. Tapardel F. Carr, M. A Rahman, C Howel-Ridell, L. Nickerson, & M. Pound N. Kassam, N. McMurtry, P. Mathura, S. Marini, & T. Chan S. Turvey, S. Smith, D. Friedman, B. Jugdutt, & P. Mathura

Using Quality Improvement (QI) Methodology to Develop a Standardized QI Educational Curriculum for Internal Medicine Residents Using the ‘Confusion Assessment Method’ Tool to Screen for Delirium Amongst Hospitalized Inpatients a Quality Improvement Initiative.

Edmonton Zone, Department of Medicine Access Partnership Project Access to Care Survey Audit Tool and Action Planning

Improving Cervical Cancer Screening Rates in HIV-positive Women

Supervisor/Sponsors Page # B. Ballermann

12

Y. Suranyi & AHS Quality Innovation Fund

13

B. Ballermann & N. McMurtry

14

M. Melia

15

D. Paulson, & AHS Quality Innovation fund

16

5

S. Shojai, P. Mathura, S. Skutle, S. Khosla, C.Dufrat-Hirt, S. Cockfield, K. Worton, D. Paulson, N. Kassam, K. Wen B. Braam, J. Abele, S. Scott R J R Cicio, J. Heck, C. Johns M. Hunsche, & R. Moore

6

A. Wrubleski, R. Hurowitz, S. Li, H. Asafo-Akowuah, P. Mathura, & A. Tapardel

Implementation of the Canadian Nutrition Screening Tool on the General Internal Medicine Units at the University of Alberta Hospital

Y. Suranyi & N. Kassam

17

7

L. Zhou, S. Shapka, P. Mathura, H. Asafo-Akowuah, D. Sinclair, B. Zukowski & A. Tarpadel

University of Alberta Hospital General Internal Medicine Units - Ensuring Adequate Nutritional Intake and Reducing Oral Nutritional Supplement Wastage

N McMurtry

18

N. Veronovici, A. Foster, & N McMurtry

19

K. Damji

20

K. Macmillan, & N. Kassam

21

8

9

S. Williams, P. Mathura, J. Wilson & N. Veronovici R. Al-Agha, Dr. H. Strungaru, H. Salmonson, K. Drader, K. Gregg & K. Damji

10

P. Barber, P. Mathura, L. Chivers, & A. Brisebois

11

H. Leon, R. Daloise, A. MacDonald, K. Maier, S. Moore, Y. Hassaan & P. Mathura

12

S. Taylor, P. Mathura, J. Zhang, P. Barber & N. Kassam

Living Kidney Donor Program Hero Assessment Process

University of Alberta Hospital Pet Healing Program: Determining Capacity, Capability and Clinical Outcomes for Program Improvement Implementing a New Diabetic Algorithm for Ophthalmology Day Surgery Patients at the Royal Alexandra Hospital Grey Nuns Community Hospital Emergency Department General Internal Medicine Physician Consultation and Triage Process

Sturgeon Community Hospital: From the Emergency J. Cesarz, Department General Internal Medicine Consultation and W. Tanaka-Collins Triage Service (GIM-ED) to the Hospital Medical Consult D. Sheps Service (PDSA #2) University of Alberta Hospital (UAH) GIM ED Evening Service: Formalized on-call staff physician check-in

8

Y. Suranyi & AHS Quality Innovation Fund

22 23

Poster Presentations

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

Author(s)

Project Title

24

Enhancing Care in the Community, N. McMurtry & C. Osbourne

25

Improving the Efficiency of Handover in Pediatrics: A Resident-Led Quality Improvement Project

T. Kherani & AHS Quality Innovation Fund

26

Alberta Health Services (AHS) Workplace Health & Safety Programs and Creating a “Culture of Quality Improvement”: Applying AHS Improvement Way (AIW) Principles to the Fit Test Designate Program

S. Tsekrekos

27

J. Tankel, and The Dept of Obstetrics & Gynecology, Royal Alexandra Hospital

28

MJ. Karathra, A. Parker, D. Sawler, P. Mathura, & L. Sun

14

L. Sonnema, L. Deuchar, D. McCallum, N. Kassam, R. Padwal, & R. Damant

15

Z. Bhaloo, N.Pereira, C. Champigny, J.Walton, & T. Kherani

16

A. Amin

17

K. Greeff, J Mateshaytis

An Alphanumeric Paging System: An Ogoing Quality Improvement Project

18

I. Colmers-Gray, N. Lam, A. Mallia, K. Morch, R. Schonnop, K. Skoblenick, C.Desrochers, J. Hayward, A. Hegstrom, E. Chang, & A. Hanson

Implementing a Procedural Sedation Checklist as a Quality Improvement Initative

19

K. Hamming, G. Noel, M. Ghosh, A. Lam, L. Mereu, A. Opgenorth, & R. Yeung

20

W. Sia, T. Workineh, B. Romansky, T. Meunier, J. Minsos, S. Zia, & N. Bakshi

21 22 23

L. Russell

24

L. Russell, A. Lee, H. Rempel, D. Perez, G. Noel, M. Mohamed, P. D’Souza, D. Baumgart, S. Van Zaten, R. Sultanian, S. Zepeda-Gomez, B. Halloran, N. Kassam, P. Mathura, & A. Kohansal

25

S. Marini

Page #

Y. Suranyi & AHS Quality Innovation Fund

13

K. Samways, P. Mathura, & M. Gill P. Mysore, P. Mathura, J. Garside, K. Zhang, & M. Sikosana

Supervisor/Sponsors

Improving Timely Treatment of Patients with Suspected TTP University of Alberta Edmonton Zone Virtual Hospital: Development of a New Care Model

Understanding the Educational Needs of Patients with Adrenal Insufficiency

A Standardized Order Set with a Structured Process was Effective in Reducing Unnecessary Bloodwork in the Alternate Level of Care Inpatients Reducing Inappropriate Lab Ordering in General Internal Medicine Units at the Misericordia Community Hospital

29 Division of Endocrinology & Metabolism & The Physician Learning Program

30

Donalda Dyjur

31

A. Morins, & N. Kassam

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U. Qarni, N. Kassam AHS Quality Innovation Fund P. Mathura, University of Alberta Hospital (UAH) Standardizing GI D. Baumgart, On Call Redsident Handover & A. Kohansal Reducing Inappropriate Lab Ordering on Unit 5A4 A Quality Improvement Initative

Targeting Incomplete Bowel Preparations for Inpatient Colonoscopies

Enhancing Physician Engagement and Leadership in Health System Transformation

9

33 34

AHS Quality Innovation Fund, Vessie Heckbert Memorial Summer Research Award & Physician Learning Program

35

N Kassam, P Mathura & N. McMurtry

36

Edmonton Zone Medicine Quality Council Strategic Clinical Improvement Committee Partnerships in Action

Scoring Criteria 1 = Poor 5 = Excellent

Oral Presentation Scoring Criteria

1 2 3 4 5

Clarity and Justification of the QI project

1 2 3 4 5

Appropriateness of the QI methods used

1 2 3 4 5

Validity and relevance of the QI Issue

1 2 3 4 5

Quality of the discussion and conclusion

1 2 3 4 5

Visual layout and visual Impact

1 2 3 4 5

Oral response to adjudicator’s question TOTAL SCORE

Poster Scoring Criteria

30

1 2 3 4 5

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 Relevance of the PDSA interventions to the Aim statements

1 2 3 4 5

Visual poster layout and visual impact

1 2 3 4 5

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

10

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Using Quality Improvement (QI) Methodology to Develop a Standardized QI Educational Curriculum for Internal Medicine Residents AUTHOR NAMES: C. Collins, P. Mathura, N. Kassam and A. Tapardel SUPERVISOR/SPONSOR NAME(S): B. Ballermann INTRODUCTION: Currently, core internal medicine residents at the University of Alberta do not have a standardized quality improvement (QI) educational curriculum. Our goal was to develop and implement a formal QI curriculum using QI principles by providing all core internal medicine residents the Evidence-based Practice for Improving Quality (EPIQ) training course, have resident teams develop potential QI projects during the course, identify resident QI champions to coach future EPIQ sessions, and align residents to active QI projects with staff physicians and multidisciplinary teams.

METHODS: Three cycles of the EPIQ course was delivered to PGY-1, PGY-2 and PGY-3 cohorts (110 residents).

Residents were grouped into teams of 6-10 to learn QI principles through developing potential QI projects. Residents then presented their QI projects at an assigned academic half-day in April 2018 and were evaluated by a designated QI consultant.

RESULTS: A post-EPIQ course survey was conducted to evaluate knowledge acquisition of QI principles, likelihood to take part in future QI projects, and interest in becoming an EPIQ facilitator. 98% of residents felt they had acquired a basic understanding of QI principles (56% increase from the baseline survey), 94% of PGY-2 and PGY-3 residents preferred this method of learning QI to the previous years (predominantly self-directed learning and completion of online modules), 40% more residents are interested in pursuing a QI project, and 17% of residents are interested in being EPIQ facilitators.

CONCLUSIONS: Overall, the written and verbal feedback obtained from residents has been overwhelmingly positive.

Developing a QI curriculum using validated QI tools highlighted the areas of change opportunity supporting change acceptance and sustainment. As more residents and staff physicians become comfortable using QI principles and become engaged in QI projects, this will foster and support a QI culture within our hospitals and healthcare system to create positive change in the future.

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Using the ‘Confusion Assessment Method’ (CAM) Tool to Screen for Delirium Amongst Hospitalized Inpatients – a Quality Improvement Initiative.

AUTHOR NAMES:

F. Carr, M. A Rahman, C Howel-Ridell, L. Nickerson and M. Pound

SUPERVISOR/SPONSOR NAME(S):

Y. Suranyi and AHS Quality Innovation Fund

INTRODUCTION

Delirium is an acute, fluctuating, confusional state, associated with significant mortality and morbidity amongst hospitalized patients. Currently, no standardized process exists for delirium screening by nursing staff. The CAM (confusion assessment method) is a validated delirium screening tool which has the potential to standardize and improve delirium screening by nursing staff.

METHODS

This study was conducted on the ACE unit at the University of Alberta Hospital, Edmonton, from June to August 2018. 7 educational sessions were conducted with nursing staff, which included CAM training and practice scenarios. The CAM was implemented for delirium screening for all patients at the time of unit admission, then twice daily. Results were documented using the CAM tracking log. Weekly plan do study act (PDSA) cycles were conducted. Outcome, process and balancing measures were calculated from the pre/post intervention data and from the PDSA evaluations.

RESULTS

139 patients were screened with the CAM. Admission CAM screening was consistently high (91%). There was significant variation in how often the CAM was used and its documentation by nursing staff. The CAM correctly identified delirium in 21 of 22 cases (95%), and was associated with a decreased incidence of falls and use of physical and pharmacological restraints. The financial costs associated with the study were minimal ($210 in total).

CONCLUSIONS

The CAM is a validated delirium screening tool which can be used by trained nursing staff to both standardize the delirium screening process and aid recognition of delirium cases. Ensuring adequate training of nursing staff in its use and documentation, alongside ensuring adequate communicating of the CAM results to the healthcare team is crucial to the process. Delirium screening with the CAM by nursing staff was associated with a significant reduction in important clinical complications (falls and pharmacological and physical restraint use); however, long term data is required to determine its impact on delirium duration and length of stay.

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Edmonton Zone, Department of Medicine Access Partnership Project (APP) Access to Care Survey Audit Tool and Action Planning Author Name(s): N. Kassam, N. McMurtry, P. Mathura, S. Marini, T. Chan SUPERVISOR/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 within the Department of Medicine in order to improve care delivery. The project was segmented into 5 phases.

Phase 1 involved the development of draft referral guidelines for 12 sub-specialties that will be uploaded into the Alberta Referral Directory (ARD). 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.

METHODS: An online survey comprising of 20 questions related to referral, wait list, and wait time management.

The survey was developed and administered through Survey Select to identify strengths and opportunities in relation to implementing the P2C framework. The results of the survey allowed programs / services to see how closely each is to meeting the Path to Care Standards / Wait Time policy. Completed by front-line staff who manage the referral and scheduling process. Complete Business Assessment Survey using multiple learning modalities: In-person presentation, Skype Sessions, and Webinar.

RESULTS: Path to Care analyzed the results and provided a summary report which will inform action planning and next steps. 100% of all communication standards are being addressed within the DoM. Inconsistencies were reflected in the process and time intervals for the standards. It is repeated after implementation as a post implementation evaluation.

CONCLUSIONS: 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

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Improving Cervical Cancer Screening Rates in HIV-positive Women AUTHOR NAMES: S. Turvey, S. Smith, D. Friedman, B. Jugdutt, and P. Mathura SUPERVISOR/SPONSOR NAME(S): M. Melia INTRODUCTION HIV-positive women are at increased risk of cervical cancer, as causative human papilloma virus (HPV) infections can result in accelerated oncogenesis in immunocompromised patients. As an effective means of screening for cervical cancer, regular Pap smears are essential in this vulnerable population.

However, currently only 72% of HIV-positive women in the Northern Alberta Program (NAP) HIV clinics are meeting the minimum standard for cervical cancer screening per established HIV clinical care guidelines METHODS To investigate this problem, we have taken a mixed-method approach using both quantitative and qualitative analysis. Qualitative analysis was performed by means of: 1) Gemba walks at the different clinic sites, which involved meeting staff and observing clinic space and workflow in real-time; 2) Process Mapping to determine the existing workflow and space for improvement; and 3) creation of a Causeand-Effect diagram for grouping the various causes of the existing problem. Quantitative analysis involved a chart review of all female NAP patients to determine the dates of patients’ last Pap smears and key patient demographics that might affect guideline compliance.

RESULTS Several opportunities in the existing system were identified. The largest barrier to screening was that patients in need of a routine Pap smear were not identified until the day before their appointment. This amount of time was insufficient to prepare for optimal clinic workflow, resulting in the screening being omitted. Communication with family physicians and availability of screening outside the HIV clinic were other identified concerns. Many unscreened patients were not being closely followed or, for personal or cultural reasons, were unwilling to have their family physician complete the Pap smears. Patients were often not aware of the importance of screening and so would not initiate screening.

CONCLUSIONS Several interventions were developed to address the identified gaps. We plan to begin the first cycle of change on October 1st, 2018. Our primary intervention is to activate functionality in the electronic medical record (e-Clinician) that will allow clinic staff to track Pap smears and automatically flag overdue patients, thereby increasing the time available for scheduling these patients to optimize clinic workflow.

Secondary interventions include an overdue patient “hotlist” to be provided to booking clerks, patient education via pamphlets and discussion with infectious disease physicians, packaging standardized Pap smear kits to facilitate screening in clinic, and better communication with family physicians regarding screening guidelines via physicians’ clinic notes and updating the Alberta Referral Directory.

Process and outcome measures of each intervention will be reviewed in November 2018.

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Living Kidney Donor Program - Hero Assessment Process AUTHOR NAMES: S. Shojai, P. Mathura, S. Skutle, S. Khosla, C. Dufrat-Hirt, S. Cockfield, K. Worton, D. Paulson, N. Kassam, K. Wen, B. Braam, J. Abele, S. Scott, R J R Cicio, J. Heck, C. Johns, M. Hunsche, and R. Moore SUPERVISOR/SPONSOR NAME(S): D. Paulson and AHS Quality Innovation Fund INTRODUCTION: Compared to chronic dialysis, kidney transplantation(KT) in eligible patients with end-stage renal disease (ESRD) is associated with better patient survival, improved quality of life, and lower healthcare costs (transplanting 10 more patients per year, can save healthcare system approximately $7.2 million over 5 years).

However, many patients die waiting for KT due to the growing gap between demand and supply of organ.

Therefore, living donor kidney transplant (LDKT) is the realistic way to save lives. In Alberta, ESRD prevalence has increased 40% over the last decade but 19 out of 20 of Albertans under the age of 60 with ESRD start on dialysis (suboptimal treatment) instead of kidney transplantation. Our data (2016) shows LKD evaluation process takes almost one year and requires at least 13 encounters between the potential donor and the health system which has a direct impact on the number of potential kidney donors accounting for our only 14% conversion rate of potential donors to actual donors.

METHODS: Using a combination of Model for Improvement and LEAN methodology, a multidisciplinary QI team was developed. After completing Gemba walks and Value-Stream Mapping, wastes in the process were recognized. QI team redesigned a new patient-centeredassessment process with defined standard work, which consists of a one day of initial assessment and one day of hospital assessment, two days in total instead of 7 months. 1:1 meetings with salient stakeholders were held, new process was simulated, and a patient journey map and a patient reflective journal were prepared. In the first plan do study act (PDSA) cycle one patient experienced the process. Based on the findings of PDSA#1, PDSA #2 was designed and expanded to 3 patients to experience this process before implementing and spreading it as the standard process.

RESULTS: The first patient one-day assessment was completed successfully (PDSA#1).

Patient arrived at 7:05 and was approved for kidney donation at 16:35 the same day. The patient was very satisfied with the process. Next PDSA (#2) will consist of 3 one-day patient evaluations of this process. Takt time was 570 minutes, diagnostic assessment time and the number of encounters were reduced by more than 90% (276 days to 21) and 80%(10 to 2).

CONCLUSIONS: LKD assessment time can be reduced significantly by continuous quality improvement. Further study on sustainability of the new process is required.

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Implementation of the Canadian Nutrition Screening Tool on the General Internal Medicine Units at the University of Alberta Hospital AUTHOR NAMES: A. Wrubleski, R. Hurowitz, S. Li, H. Asafo-Akowuah, P. Mathura, and A. Tapardel SUPERVISOR/SPONSOR NAME(S): Y. Suranyi and N. Kassam INTRODUCTION: Malnutrition is prevalent in up to 45% of inpatients in Canadian hospitals. Despite this, less than 23% of malnourished patients receive registered dietician (RD) consults. Malnutrition has been associated with numerous adverse clinical outcomes including increased length of stay, infection risk and mortality. The Canadian Malnutrition Task Force (CMTF) recently developed the Canadian Nutrition Screening Tool (CNST) as a validated nutrition screen for patients admitted to inpatient medical/surgical wards to help identify patients at nutrition risk. Currently, the general internal medicine (GIM) wards at the University of Alberta Hospital (UAH) do not regularly screen patients for malnutrition. As a result, we hypothesize that a large proportion of patients at nutritional risk are not being identified or have a significant delay to RD referral. Our quality improvement (QI) project aimed to: i) Evaluate the implementation and uptake of the CNST on the general internal medicine wards ii) Measure the impact of the CNST on cycle time to RD consult.

METHODS: Current state process mapping and baseline data was gathered cross-sectionally from patient charts on the GIM wards. Labels designed with the CNST were created and unit clerks on GIM wards (5D2, 5D3, 5D4) were instructed to place labels onto the first progress note of all admitted patients. Beginning July 11, 2018, all residents and clinical clerks were instructed to complete the CNST on all admitted patients. Those deemed at risk of malnutrition as per the CNST required RD consultation. Charts of all discharged GIM patients after July 11th underwent audit by a QI team member. Data was recorded into REDCap database and baseline data analysis was conducted via Student’s t-Test.

RESULTS: A total of 194 patient charts were audited, n=75 pre-implementation and n=119 post-implementation.

Process measure of CNST completion in PDSA 1 (n=66) and PDSA 2 (n=53) was 33.3% and 20.8% respectively. Outcome measure of cycle time to RD consultation prior to implementation was an average of 9.86 (SD 5.0) days versus 2.76 (SD 5.2) days post-implementation (p<0.001), mean difference=7.1 days.

CONCLUSIONS: Implementation and completion of CNST reduces cycle time to RD consultation. Completion rate of CNST was lower than expected. Future steps evaluating the involvement of nursing staff to complete the CNST will likely increase its uptake. Furthermore, incorporating the CNST into the incoming EHR (electronic health record) will likely prompt practitioners to complete the CNST more consistently.

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University of Alberta Hospital (UAH) General Internal Medicine (GIM) Units - Ensuring Adequate Nutritional Intake and Reducing Oral Nutritional Supplement Wastage AUTHOR NAMES: L. Zhou, S. Shapka, P. Mathura, H. Asafo-Akowuah, D. Sinclair, and B. Zukowski and A. Tarpadel SUPERVISOR/SPONSOR NAME(S): N. McMurtry INTRODUCTION: Oral nutritional supplements (ONS) are ordered for patients who are malnourished or self-requested by the patient. Due to fluctuating patient conditions, overprescribing, and inconsistent follow-ups, ONS accumulation and waste has been identified as a problem throughout hospitals in Alberta to be targeted by the Nutrition and Food Services department. Staff at the UAH GIM units began raising awareness of ONS waste in November 2017, which led to the formation of a quality improvement team in March 2018 to target this concern.

METHODS: The Model for Improvement framework was used to guide the quality improvement project. A Gemba walk, baseline audit, and stakeholder meeting was conducted to determine the main process steps and identify root causes. Arising interventions were developed and tested in multiple PDSA cycles to reduce ONS waste, initially in 5D3 and with plans to scale to the five UAH GIM units. Change management was facilitated using Lewinâ&#x20AC;&#x2122;s Unfreeze-Change-Refreeze model and the ADKAR model.

RESULTS: Root causes leading to ONS accumulation were determined to be overprescribing, limited accountability, and lack of automated stop or flagging system. 6 ONS were found in a single day audit on unit 5D3 in March. PDSA #1 trialed a labor intensive tracking system where food services workers counted ONS by bedside. The dietitian reported adjusting total of 3 patient supplement orders subsequent to the tracking. Consequently, PDSA cycle #2 focused on training RNs and RDs to initially prescribe maximum 1 ONS daily and RDs will use the CBORD census report to highlight patients on >/= 2 ONS bottles daily for UM follow-up. PDSA cycle #3 included implementation of MedPass, which is a process to administer medications alongside ONS from the same bottle until fully consumed by the patient.

CONCLUSIONS: The Hawthorne effect greatly reduced accumulation of ONS seen at baseline on the GIM units. Interventions tested in the PDSA further increased awareness of ONS accumulation, improved communication between food service, nurses, and dietitians, and created shared accountability. Ultimately, the interventions led to reduction in accumulating ONS and ensured that patients with poor nutritional status were monitored.

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University of Alberta Hospital (UAH) Pet Healing Program: Determining Capacity, Capability and Clinical Outcomes for Program Improvement AUTHOR NAMES: S. Williams, P. Mathura, J. Wilson and N. Veronovici SUPERVISOR/SPONSOR NAME(S): N. Veronovici, A. Foster, and N McMurtry INTRODUCTION: The University of Alberta Hospital (UAH) Pet Healing program is an important healthcare care initiative delivered to thousands of patients every year by Volunteer Resources. Every year we provide therapeutic dog visits to patients and families on over 60 different units throughout UAH campus. The goals of this QI project are to: a) track the appropriate business metrics to facilitate future program growth, b) capture the benefit and clinical impact of this program, c) develop a communication plan to increase program awareness and share program offerings and d) standardize the referral process to better support requests for services and summarize appointment data.

METHODS: The Donabedian model of structure, process and outcome supported the development of a driver document which identified program areas for in-depth assessment along with identifying change interventions that were tested using iterative plan do study act (PDSA) cycles. A SWOT analysis supported the development of the change interventions ensuring the alignment to our project objectives.

To determine clinical metrics, a literature review was created and physicians from geriatrics and physiatry provided clinical knowledge and expertise.

RESULTS: As part of our PDSA cycles the following was achieved: The current state analysis yielded vital information super users and program champions. Staff surveys (108/174, 62% completion rate) provided realistic appraisal of program awareness and areas of strengths/weaknesses. The referral process was streamlined supported by the development of a referral form and an email address pet.program@ahs. ca. These data are now tracked in Excel for data analysis. Standard operating procedures regarding program administration were completed and 2 new volunteers were trained for program administration, improving day-to-day operations. A communication plan was developed and implemented. A clinical impact study of the pet program has been started; an internal literature review and ethics submissions have been completed.

CONCLUSIONS: This QI approach provided tremendous insight on how the pet program functions and is perceived at the UAH. The Pet Healing program is seen as very successful in improving the emotional and physical well-being of patients by staff, but awareness of how to make referrals must be improved. The gathered business metrics will help the program plan future expansion.

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Implementing a New Diabetic Algorithm for Ophthalmology Day Surgery Patients at the Royal Alexandra Hospital (RAH) AUTHOR NAMES: R. Al-Agha, Dr. H. Strungaru, H. Salmonson, K. Drader, K. Gregg & K. Damji SUPERVISOR/SPONSOR NAME(S): K. Damji INTRODUCTION: The Outpatient Day Surgery Service at the RAH serves upwards of 40 patients/day. Patients with diabetes mellitus scheduled for eye surgery are tested for glucose levels on the morning of the surgery.

Patients are instructed to withhold oral hypoglycemic on the day of surgery. When the blood glucose is high, patients received insulin infusion protocols as part of the regular glucose control in diabetic patients at our institution. From August 2016- July 2017 there were 13 RLS reports filed regarding this diabetic protocol being used. The majority of these reports were problems related to the initial set up of the protocol and how the protocol was handled incorrectly in the operating room (OR). Multiple hypoglycemic incidents were documented related to this protocol. This diabetic protocol requires approximately 30 minutes and two nurses to set up.

Problem: Insulin infusion pumps set up is complex, compromises patient safety and can lead to costly operating room delays.

Goal: Develop and implement a new diabetic algorithm to safely treat diabetic patients; decrease the patient’s pre-op preparation time and prevent errors from occurring.

METHODS: A multidisciplinary project team was assembled including Ophthalmologists, Endocrinologists, Anesthesiologists, Professional practice, Management and Nurses. Results from a literature review provided strong evidence that the insulin pump caused many hypoglycemic events. Leveraging best practices from literature a new diabetic protocol to safely treat diabetic patients prior to eye surgery was developed. The new protocol utilizes the insulin pump only when blood glucose is higher than 20 mmol/L. The team also created and implemented a real-time tracking tool to support the new algorithm that collects information (process-protocol use and outcome measures-adverse events reduction) measuring the effectiveness of the new protocol. Implementation of the new diabetic algorithm occurred on August 1, 2017.

RESULTS: August 1, 2017 to July 31, 2018 there have been zero RLS reports submitted related to the diabetic algorithm. No reports of pre-op or post-op hyper/hypo glycemic events were reported through the RLS system. Intervention data shows that an average of 2.5% (2) diabetic patients per month require the insulin pump after implementing the new protocol. This is a 97.5% reduction in the use of insulin pumps for diabetic patients, thus decreasing nursing time (new diabetic algorithm takes approximately 7 minutes to initiate and can be successfully set up by one nurse), error rate, OR delays and cost. This innovative protocol will be shared with other hospitals within the Edmonton zone.

CONCLUSIONS: The core improvement team championing this test of change was vital to making this initiative a priority within the hospital ophthalmology surgery department. Improving patient safety and hospital experience were key motivating factors to successful innovation and implementation. Implementing the real-time tracking tool to view on-going effectiveness proved challenging and will be encouraged as protocol use continues.

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Grey Nuns Community Hospital - Emergency Department (ED) General Internal Medicine (GIM) Physician Consultation and Triage Process AUTHOR NAMES: P. Barber, P. Mathura, L. Chivers, and A. Brisebois SUPERVISOR/SPONSOR NAME(S): K. Macmillan, and N. Kassam INTRODUCTION: The Grey Nuns Community Hospital (GNCH) has approximately 75,000 ED visits annually with an average Emergency In Patient Length of Stay (EIP LOS) of 26-28 hours. GIM Physicians must care for both ward and ED patients simultaneously. This leads to GIM physicians working longer ward hours due to frequent pages and visits to the ED. Similarly, ED physicians must wait for available GIM physicians for consultations, have increased ED physician handovers and delayed ability to transfer patients to the wards. The project aims to improve Medicine patient flow through the GNCH ED and ward by developing an ED GIM consultation service, streamlining the consultation/disposition process and allocation of patients to the appropriate medical service team.

METHODS: Benchmarking of other Edmonton Zone (EZ) hospitals and a literature review provided insight into opportunities to impact the GIM physician schedule. Process assessment steps within the GNCH included multiple physician engagement sessions, a Gemba walk, a pre-post survey and a review of ED data.

The main opportunity for improvement identified was the physical placement of a GIM consult physician directly within the ED from 0700-1700 Monday to Friday. A 3 month Plan-Do-Study-Act (PDSA) cycle to evaluate the service impact was completed. Supporting the change initiative and acceptance, frontline project champions led weekly sessions capturing real time issues along with solution tracking and supported consistent physician attendance at bed management meetings.

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

CONCLUSIONS: GIM ED Physician service has a direct impact on both ED and ward patient flow; strengthens interdisciplinary teamwork and communication. Change management approaches and frontline project champions support increased cultural acceptance of this improvement opportunity.

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Sturgeon Community Hospital (SCH): From the Emergency Department General Internal Medicine Consultation and Triage Service (GIM-ED) to the Hospital Medical Consult Service (HMCS) (PDSA #2) AUTHOR NAMES: H. Leon, R. Daloise, A. MacDonald, K. Maier, S. Moore, Y. Hassaan and P. Mathura SUPERVISOR/SPONSOR NAME(S): J. Cesarz, W. Tanaka-Collins and D. Sheps INTRODUCTION: Emergency Department (ED) crowding continues to be one of the major problems facing the Sturgeon Community Hospital (SCH). Data suggests that the sturgeon community hospital (SCH) has seen a remarkable increase in the number of ED visits from elderly patients with complex needs amounting 11.6% increase in the first 6 months of 2018. The SCH ED has seen as well a 16% increase in average EMS dispatches per month during 2018. Literature suggests that patients with more complex comorbidities are more likely to undergo multiple consultations and might stay longer in ED before a decision is made for admission or discharge from ED. In view of this increase in number of visits, we have seen a steady increase in the total ED waiting times especially for admitted patients (average of 38 hrs.) and heightened burdens on staffs to deliver the expected high quality care to their patients. Literature also suggests that when patients experience delays in treatment or are boarded in emergency rooms, outcomes are worse and costs are higher. The aim of this project is to present the results of the second PDSA cycle (extended from March 5th to June 30th, 2018).

METHODS: Based on the above, we developed a multifaceted medical consultation service and tested it through two PDSA Cycles. We implemented an evidence based protocol for Internal Medicine consultation services and conducted an extensive evaluation through quantitative and qualitative data collection and analysis. Utilized the model for improvement and Demingâ&#x20AC;&#x2122;s iterative plan do study act cycle.

RESULTS: Results reflect an overall decrease in ED waiting time (37% reduction), a subtle reduction in percentage of elderly admissions (3% reduction) and slight increase in percentage of discharges from ED (3% increase) despite of the 4% increase in volumes of elderly visits and 31% incredase in patients seen

by HMCS during PDSA 2 who were discharged from ED. CONCLUSIONS: Despite the increase in demand on ED services, we were able to implement specific strategies to effectively decrease waiting time and ensure that stable patients are being discharged to the right destination in a more timely fashion.

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University of Alberta Hospital (UAH) GIM ED Evening Service: Formalized on-call staff physician check-in AUTHOR NAMES: S. Taylor, P. Mathura, J. Zhang, P. Barber and N. Kassam SUPERVISOR/SPONSOR NAME(S): Y. Suranyi and AHS Quality Innovation Fund INTRODUCTION: General Internal Medicine (GIM) Emergency department (ED) consult service provides 24hr coverage at the University of Alberta hospital (UAH). Three shifts of approximately 8 hours, each is staffed during the day with a GIM staff physician and during the evening and night shifts with senior residents (PGY2 and PGY3 GIM residents). The busiest time in the UAH ED overlaps with the GIM evening shift and not all patients seen by the GIM ED consult service require admission, but some would benefit from GIM outpatient follow-up/disposition. These patients cannot be discharged from the ED until they have been assessed by a GIM staff physician and so they are typically ‘held-over’ until a GIM staff can review their case in the morning. These held over patients have extended ED visit times, decrease patient experience, take up ED beds, and disrupt ED patient flow. Approximately 9% of GIM consults during the evening shift fall into this category representing a promising patient-cohort to intervene upon and further optimize.

METHODS: To review the current GIM ED consultation process a detailed process map outlining both process strengths and opportunities was developed. Utilizing the Model for Improvement and the Deming cycle (PDSA-Plan Do Study Act) the proposed solution was piloted for 4 months; wherein on-call GIM staff would check-in with the evening GIM seniors at 1700hr and between 2100-2200hr and physically come into the ED. Review consults, see ‘hold-over’ patients, and discharge them in a timelier fashion. Provide further back-up support for their senior residents. To evaluate if this change was an improvement both quantitative and qualitative data were collected; consult time and length of stay (LOS) for hold-over and admitted patients were reviewed. ED and GIM physicians and GIM senior residents were surveyed to determine their perspective on this intervention.

RESULTS: PDSA cycle-April to July of 2018 showed a 15% reduction in the length of stay (LOS) for ‘hold-over’ patients and the time for all GIM consults (Admissions and hold-over patients) decreased by 16%.

Nearly 70% of GIM senior residents, GIM and ED physicians felt that this had reduced the number of ‘hold-over’ patients and 80% of senior GIM residents reported feeling more supported by their GIM staff. This PDSA also identified areas for future optimization, including further clarifying GIM staff roles during these check-in periods, and encouraging them to check-in/review and discharge ‘hold-over’ patients. Nearly 45% of GIM staff reported that this change had increased their overall workload, thus further study of the effects of this intervention on GIM staff wellbeing and how best to mitigate burnout is suggested.

CONCLUSIONS: The preliminary results from the first cycle of change are promising and provide a strong foundation to continue and further optimize the GIM staff ED consultation check-in process.

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Improving Timely Treatment of Patients with Suspected TTP University of Alberta AUTHOR NAMES: MJ. Karathra A. Parker, D. Sawler, P. Mathura, and L. Sun SUPERVISOR/SPONSOR NAME(S): Y. Suranyi and AHS Quality Innovation Fund INTRODUCTION: Thrombotic thrombocytopenic purpura (TTP) is a life-threatening condition that must be treated as a medical emergency to ensure that patients receive timely access to life saving plasma exchange.

Plasma exchange, also referred to as plasmapheresis, has reduced mortality from as high as 90% to 10-20%. UK guidelines recommend initiating plasmapheresis in patients with suspected TTP within 4-8 hours of presentation. Timely definitive management of TTP is not being achieved in Northern Alberta. The current time from suspected diagnosis to plasmapheresis is 15.5 hours at the University of Alberta Hospital (UAH), the only centre with apheresis capacity in Northern Alberta. Delays in initiating plasmpheresis may directly impact patient outcome/mortality.

Our aim was to identify and implement salient interventions using cycle time analysis and the Shewhart Plan-Do-Study-Act iterative cycles to decrease the current cycle time within the TTP patient journey to achieve timely plasmapheresis treatment.

METHODS: To define the problem and build understanding of the current process, a systematic quality improvement (QI) approach was used. The QI method included value stream mapping, cycle time and root cause (Ishikawa) analysis to identify areas of improvement opportunity. A chart audit of baseline data from patients presenting with suspected TTP from 2016-2017 showed that 9.3 hours was the median amount of time it took for a patient to receive plasmapheresis after arriving to the UAH emergency department. The greatest delay in patient care was in waiting for central line insertion by a trained physician, with a median wait time of 4.7 hrs. Among those with >8-hour delays from time of diagnosis and initiation of plasmapheresis, only 17% received plasma infusions. Plan-Do-Study Act cycles will provide the framework to test the change interventions.

RESULTS: Based on baseline data, several interventions were identified. To address central line insertion as a source of delay, ICU and interventional radiology physicians were informed of urgent need to insert central lines on patients with suspected TTP. Selected dialysis nurses were cross-trained in plasmapheresis and may provide after-hours plasmapheresis coverage, as PLEX is not available at UAH between 24:00 â&#x20AC;&#x201C; 08:00. Hematology staff were informed to 1) order hemolysis workup as a STAT order to ensure lab work returns within 1 hour, 2) order plasma infusions for those with anticipated long delays to definitive treatment, as well as to 3) book transportation through RAAPID and to verbally request the patient to be transported as level red.

CONCLUSIONS: Through this project, we identified that communication gaps between medical services, transportation providers, and lab services are driving forces behind delays in treatment. Addressing these communication gaps will allow UAH to decrease cycle time, ultimately improving quality of patient care for those diagnosed with TTP.

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Edmonton Zone Virtual Hospital: Development of a New Care Model AUTHOR NAMES:

L. Sonnema, L. Deuchar, D. McCallum, N. Kassam, R. Padwal and R. Damant

SUPERVISOR/SPONSOR NAME(S):

Enhancing Care in the Community, N. McMurtry and C. Osbourne

INTRODUCTION

In April 2018, the Edmonton Zone Virtual Hospital (EZVH) team began enrolling patients who were both currently an acute care inpatient at the University of Alberta Hospital and living with complex health issues with high risk of re-admission. At its foundation, the EZVH aims to support the development of trusting partnerships among health system providers to support seamless transitions for patients across the health care continuum. The potential benefits of the person centered, technology enabled model include improved clinical outcomes, improvements in the patient, family/caregiver and provider experience and a reduction in system usage and costs (reductions in acute care length of stay, acute care readmissions, and emergency department usage).

METHODS

The EZVH model was developed using an action based, provider driven approach to co-design. The plan-dostudy-act (PDSA) framework supports continuous learning and innovation.

RESULTS

In 7 months (April to September 2018), 20 patients have been enrolled into the EZVH integrated care model.

Feedback from patients and families has been very positive and anecdotal feedback support early successes related to system navigation and medication management. The EZVH team is a critical link in whole system care and is fostering collaborative relationships, between acute care, primary care and continuing care to drive system integration.

An important learning to date is related to the number of patients whose conditions decompensate following discharge from hospital, during their time in the EZVH. This learning resulted in the co-design and implementation of a care pathway called â&#x20AC;&#x153;Unexpected Patient Deterioration in the Communityâ&#x20AC;?. This proactive process aimed at preventing Emergency Department visits, allows the individual to receive the most appropriate care at home, by community paramedic teams.

CONCLUSIONS

Conversations and planning have begun to explore the scale and spread of the model across the Edmonton Zone. While these conversations evolve, the EZVH Complex Care team will continue to lead the co-design and development of the model and use technology, as informed by the innovation lab, to further facilitate the delivery of care in the community.

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Improving the Efficiency of Handover in Pediatrics: a Resident-Led Quality Improvement Project AUTHOR NAMES:

Z. Bhaloo, N.Pereira, C. Champigny, J.Walton, and T. Kherani

SUPERVISOR/SPONSOR NAME(S):

T. Kherani and AHS Quality and Innovation Fund

INTRODUCTION:

A qualitative thematic process based on resident perceived challenges was conducted. Resident handover was observed. Resident focus groups reflecting on the thematic process while engaging residents in the Model of Improvement were conducted. Lean Six Sigma was reviewed. QI tools including root cause analysis (eg Ishikawa diagram) and process mapping were employed to develop an aim statement, outcome measures and change ideas around prioritized challenges. This will inform iterative plan-do-study-act (PDSA) cycles. Interventions will be evaluated with observed handover using a controlled before and after study design.

METHODS:

The qualitative thematic process identified content (73%), structure (55%), interruptions (36%), and late starts (36%) as major challenge themes. Resident handover was observed for each weekday. Residents prioritized interruptions, content and structure as challenges and formed working groups around these themes. Print times of handover lists, start and end times of handover, late starts and their reasons, interruptions and their sources were recorded for each team.

RESULTS:

TThe qualitative thematic process identified content (73%), structure (55%), interruptions (36%), and late starts (36%) as major challenge themes. Resident handover was observed for each weekday. Residents prioritized interruptions, content and structure as challenges and formed working groups around these themes. Print times of handover lists, start and end times of handover, late starts and their reasons, interruptions and their sources were recorded for each team.

CONCLUSIONS:

This QI project engages residents in QI methodology to improve handover, a daily component of patient care.

Handover, QI and patient safety are reflected in the CanMEDS competencies and framework as residency goals.

Improved handover efficiency can lead to improved patient safety and quality of care.

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Alberta Health Services (AHS) Workplace Health and Safety (WHS) Programs and Creating a “Culture of Quality Improvement (QI)”: Applying AHS Improvement Way (AIW) Principles to the Fit Test Designate (FTD) Program AUTHOR NAMES: A. Amin SUPERVISOR/SPONSOR NAME(S): S. Tsekrekos INTRODUCTION In its 2017-2020 “Health and Business Plan” AHS has framed each of its four organizational goals using improvement language. Within these overarching goals, AHS WHS Senior Leadership has recognized the need for a stronger “QI Culture” within AHS WHS that includes broader awareness of QI principles in addition to the integration of these principles into: 1) the evolution and evaluation of existing AHS WHS programs; and 2) the development, implementation, and evaluation of new AHS WHS Programs.

In discussion with AHS WHS Senior Leadership, the FTD Program was chosen in order to frame the application of the AIW Yellowbelt methodology in addition to certain QI tools from the Evidence-based Practice for Improving Quality (EPIQ) methodology.

METHODS Background information and qualitative data on the FTD program was collected using existing documentation, direct observation, and focused interviews. Based on this, FTD competence was chose as the area of focus to illustrate the application of QI methodology and tools. Using the AIW methodology, in addition to EPIQ QI tools, it was demonstrated how the issue of FTD competence could be addressed by: “defining the opportunity”; “building understanding”; “acting to improve”; “sustaining results”; “managing change”; and “sharing learning.”

RESULTS The issue of FTD competence was used as a “worked example” where it was shown that through a series of interventions and corresponding QI (“Plan-Do-Study-Act”) cycles, spanning approximately 2 years, a sample of recently trained FTDs would have their competence assessed at 1 year post-initial FTD training. Those FTDs with competence scores of <85% at this first competence assessment would undergo both online and in-person “refresher” training such that all the FTDs in this sample would have competence scores of ≥85% at 2 years post-initial training compared to the scores of a baseline sample of FTDs at 2 years post-initial training (who would have followed the current standard of practice of no competence assessment and a requirement to complete an online “refresher” every 2 years post-initial training).

CONCLUSIONS Thus far, this work has culminated in a presentation to AHS WHS Leadership and the production of a report with a positive response (in that it has increased awareness and receptiveness to integrating QI into AHS WHS Programs and practices). This work will be further discussed by AHS WHS Leadership with additional recommendations stemming from this project including (but not being limited to): beginning to identify additional AHS WHS Programs that are interested in, or would benefit from, QI work; and supporting a member of each AHS WHS Program team to pursue foundational AIW certification.

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An Alphanumeric Paging System: An Ogoing Quality Improvement Project AUTHOR NAMES: K. Greeff, and J. Mateshaytis SUPERVISOR/SPONSOR NAME(S): J. Tankel, Department of Obstetrics and Gynecology, Royal Alexandra Hospital INTRODUCTION: Many tertiary care centers utilize alphanumeric paging systems. According to a review of the literature, the results of switching to a message based paging system have been extremely positive. The process of text-paging sends a message that includes pertinent information to allow the recipient to triage the page appropriately - subsequently improving patient care.

METHODS: Pre-intervention Likert format surveys were distributed to OBGYN residents and L&D RNs, to evaluate the current paging practices at RAH. This included questions assessing perceptions of efficiency, ability to triage, effectiveness of communication and patient safety. The survey responses were anonymous, and collected via REDcap. The alphanumeric paging system was then implemented for a two-month trial period. Nursing staff were educated on how to page using a specific reproducible template that included the location, urgency and context of the page. Post-intervention Likert format surveys were distributed to reassess the perceptions of the paging process, and to solicit feedback on the change.

The data was collected and analyzed via REDcap RESULTS: Comparison between pre-and post intervention surveys obtained from the Labour and Delivery nurses and residents were resoundingly positive with regards to impact on patient care. Due to positive results, we have expanded the alphanumeric paging system to the OBGYN wards with ongoing data collection. Survey results from RNs demonstrated improved efficiency in communication as well as decreased time taken to respond to patient needs. Residents found that with standard numeric paging there were significant numbers of non-urgent pages that interrupted patient care. The introduction of message-based paging showed an improved ability of residents to triage urgent vs. non-urgent pages, reducing these interruptions.

CONCLUSIONS: Implementation of an alphanumeric paging system for the Royal Alexandra Hospital Labour and Delivery Unit achieved the objective of this quality improvement project by streamlining communication between nurses and residents with the goal of enhancing patient safety. The improvement of resident efficiency, response time to emergent situations and triaging abilities has led to the ongoing implementation of the alphanumeric paging system to the general OBGYN wards, with plans to extend to attending physicians in the future.

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Implementing a Procedural Sedation Checklist as a Quality Improvement Initative AUTHOR NAMES: I. Colmers-Gray, N. Lam, A. Mallia, K. Morch, R. Schonnop, K. Skoblenick, C.Desrochers, J. Hayward, A. Hegstrom, E. Chang, and A. Hanson SUPERVISOR/SPONSOR NAME(S): INTRODUCTION: Procedural sedations are a common procedure in the emergency department (ED). Though frequently performed, sedations carry a potential risk of harm. Surgeons and anesthetists have implemented pre-procedure time-outs with checklists prior to commencing an operation in attempts to mitigate procedure-related risks. Our quality improvement (QI) initiative sought to implement a similar checklist for procedural sedations performed in the ED. METHODS: A one-page procedural sedation checklist was developed based on a literature review and in consultation with relevant health professionals (respiratory therapists [RTs], MDs). The checklist was completed

by RTs at the Royal Alexandra Hospital ED over a two-month period. Completed checklists were collected anonymously. Data was summarized for further review, revision, and possible re-implementation of this QI initiative RESULTS: 108 checklists were completed during the QI period. Checklist section completions rates were 96% for pre-sedation preparation, 99% for equipment, and 85% for the MD timeout. Missing equipment was identified in 13% of checklists. One case identified a number of potential hazards before initiating procedural sedation. Overall satisfaction for the checklist was 66% for physicians, 59% for RTs and 55% for nurses. Feedback was provided on 52% of checklists. Overall satisfaction for the checklist was variable, though participants found it user friendly.

CONCLUSIONS: Implementation of a multidisciplinary procedural sedation checklist over a two-month period was well completed and helped identify missing equipment prior to sedation. The checklist allowed critical preparatory components of procedural sedation to be verbalized. Future areas of research include improving the checklist based on feedback received, and incorporating the checklist within established ED protocols

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Understanding the Educational Needs of Patients with Adrenal Insufficiency AUTHOR NAMES:

K. Hamming, G. Noel, M. Ghosh, A. Lam, L. Mereu, A. Opgenorth, R. Yeung

SUPERVISOR/SPONSOR NAME(S):

Division of Endocrinology and Metabolism and the Physician Learning Program

INTRODUCTION

The Division of Endocrinology at the University of Alberta has created a Quality Improvement (QI) team. Guided by the EPIQ program (www.epiq.ca), our Division prioritized the need to improve patient education for those living with adrenal insufficiency (AI).

METHODS

To better understand the local clinical context, we informally surveyed Edmonton endocrinologists on their current management and education of patients with AI based on chart review of their last known patient with AI. In order to check provider assumptions and to ensure patient-centred care, we partnered with a Human-Centred Designer and started AI patient engagement with a co-creation workshop. Guided by a two-member design team, five patients shared their experiences of living with AI with three endocrinologists.

RESULTS

From the survey of endocrinologists, we found marked inter-practitioner variation in what and how AI education is provided. Out of 15 endocrinologists who responded, all provided instructions on increasing glucocorticoid dose for physical stress (e.g. fever, trauma), 11 gave instructions on increasing glucocorticoid for emotional stress, while none gave instructions on increasing the dose of mineralocorticoid for hot weather or exercise.

These results suggested the need to develop a standardized toolkit to ensure that all patients receive the same high quality education for AI. As a result of the co-creation workshop, we discovered that patients agreed that a co-created toolkit would improve delivery of care for patients living with AI and have agreed to join our QI team.

CONCLUSIONS

We are currently creating an AI toolkit to improve the quality and consistency of information patients receive, which will constitute the intervention for our first Plan-Do-Study-Act cycle. We are currently creating an AI toolkit to improve the quality and consistency of information patients receive, which will constitute the intervention for our first Plan-Do-Study-Act cycle.

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A Standardized Order Set with a Structured Process was Effective in Reducing Unnecessary Bloodwork in the Alternate Level of Care Inpatients AUTHOR NAMES: W. Sia, T. Workineh, B. Romansky, T. Meunier, J. Minsos, S. Zia, and N. Bakshi SUPERVISOR/SPONSOR NAME(S): Donalda Dyjur INTRODUCTION: The Royal Alexandra Hospital Medicine program in Edmonton is approximately 360 beds, with about 30% of patients who are alternate level of care (ALC) patients (who are waiting in hospital for an institution at a lower level of care). Often the inpatient team neglects to reduce the blood draw frequency as there is no clear standard process highlighting this need resulting in unnecessary blood draw. Our objective was to develop a standardized process to reduce unnecessary bloodwork.

METHODS: Baseline lab test order volume for 2016 per month was tabulated to determine usage volume. Stakeholder engagement including physicians, nurses, unit managers and lab managers forming a QI team co-designed a process employing consensus and iterative plan do study act cycles (PDSA) to determine impact of the intervention in 13 medicine wards over 9 months. The developed standard label, order book and process was simple yet effective RESULTS: The total number of ALC patients remain constant pre- and post-intervention. PDSA started in January 2017, there has been an overall reduction of blood draws, over 9 months which equated to 4345 less ordered blood tests. Assuming each lab draw and test costs about $15, we have saved approximately $65,175 and have prevented patients from potential anemia, bruising and other negative consequences related patient experience CONCLUSIONS: Engaging frontline staff to develop and use a simple, pre-printed label with an order set and incorporating these into a standardized process on the 13 Medicine wards was effective in reducing and sustaining unnecessary blood draw in ALC hospitalized patients; which resulted in healthcare cost savings.

Using visual cues such as the pre-printed label was an effective tool that was simple to use and can be widely adopted.

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Reducing Inappropriate Lab Ordering in General Internal Medicine Units at the Misericordia Community Hospital AUTHOR NAMES: K. Samways, P. Mathura, and M. Gill SUPERVISOR/SPONSOR NAME(S): A. Morins, N. Kassam INTRODUCTION: With the increasing focus on resource stewardship in hospital care, it is important for hospitals to review proper lab ordering to reduce costs and improve patient experience. The aim of this project was to determine if inappropriate lab ordering was an issue at the Misericordia Community Hospital (MCH), and to reduce total CBC(D), electrolytes and creatinine tests ordered by 35% with a focus reduction of urea by 50% during the three-month study period of August 20, 2018 to November 30, 2018. This project is a continuation of an initial quality improvement project in GIM completed at the University of Alberta Hospital.

METHODS: A chart audit, Lab Kardex audit, and physician/nurse practitioner survey was performed to understand current ordering practices and culture. Process mapping and a cause and effect analysis was used to identify current gaps and possible solutions. Based on these solutions, Plan-Do-Study-Act (PDSA) cycles were implemented. 1 year of baseline pre-intervention lab data was analyzed to indicate the highest ordered lab tests and their costs. The primary outcome measure was the total number of CBC(D), electrolytes, creatinine and urea tests ordered on GIM units 8E, 7E & 7W, with the frequency of tests ordered daily as a secondary measure. Analysis of 1 year of lab data showed that 49% of tests ordered on GIM units 8E, 7E & 7W were CBC(D), electrolytes, creatinine, and urea. Baseline chart audit showed 63% of patients had one of these tests ordered daily at admission in the emergency department(ER), and 49% had urea ordered daily. 46% of patients continued to have urea ordered daily once they were on the ward.

RESULTS: Cause and effect analysis identified the root causes as a lack of provider education on appropriate laboratory ordering frequency, particularly for urea; lack of formal discussion on lab frequency during rounds; and lack of clarity on where to find order frequency information. Process mapping identified that physicians are not aware of a patientâ&#x20AC;&#x2122;s lab order frequency or where to find this information on the ward.

A dual sticker system was implemented, including a Urea Rationale Sticker where a clinical indication for ordering urea must be provided prior to processing the order and an auto-substitution of all labs ordered daily to daily x3. When comparing August 2018 to August 2017 we noticed a 42% reduction in CBC/CBCD, 37% reduction in electrolytes and creatinine, and a 61% reduction in urea orders.

CONCLUSIONS: The culture of ordering daily labs and lack of awareness of what labs are ordered on a patient between handover from ER to the ward led to redundant lab ordering. Simply increasing provider awareness about the importance of reviewing lab frequency and reducing daily ordering decreased total lab tests ordered. Implementing a dual sticker system to auto-substitute daily labs to daily x 3 and provide a clinical indication for ordering urea led to a 61% reduction in urea orders. Lack of awareness related to the lab test costs and system impacts was identified as a barrier, which was easily addressed by provider education. As a teaching hospital, providers should challenge routine lab ordering culture and encourage mindful ordering practices for learners to improve patient experience. As the PDSA cycle continues, lab order volume data and lab costs will continue to be analyzed to determine the full annual project impact.

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Reducing Inappropriate Lab Ordering on Unit 5A4 - A Quality Improvement Initative AUTHOR NAMES: P. Mysore, P. Mathura, J. Garside, K. Zhang, M. Sikosana SUPERVISOR/SPONSOR NAME(S): U. Qarni, N. Kassam and AHS Quality Innovation Fund INTRODUCTION Most nephrologists accept that ordering routine creatinines and ureas on chronic dialysis patients provides no clinical value. Additionally, excessive lab ordering leads to increased venous punctures (associated with vascular damage), excessive lab costs, and increased risk of hospital acquired anemia.

Therefore, we developed a multifaceted QI initiative intended to reduce inappropriate lab testing on Unit 5A4 METHODS Our interventions were guided by information gathered via multiple QI tools and implemented in sequential PDSA cycles.

Our first intervention was a teaching session on the first day of the new block orienting the physicians to the project. Paper orientation booklets were administered highlighting three main focuses: overusing ‘daily’ labs, CBC appropriateness compared to CBC with differentials, and inappropriate creatinine and ureas.

Our second intervention included all above interventions but incorporated three additional facets. Orientation packages were emailed to the residents, informational posters were displayed on the ward, and during weekly formal rounding, the appropriateness of patients’ lab orders was assessed.

For data analysis, we were provided comprehensive lab data from unit 5A4 for the 6 months preceding our project initiation, and we obtained patient specific baseline data for the week prior to our first intervention. Weekly chart audits were performed on the Team Sheets; documenting appropriateness of creatine and urea ordering. Also, comprehensive data from the lab services department showing frequency and type of labs orders on unit 5A4 were analyzed.

RESULTS We saw an overall decrease in burden of laboratory testing compared to the previous month and year.

Following our initiative, CBC with differential decreased 62.5% and CBCs increased 30%. During our initiative, the number of creatinines decreased to 126 from 306 and 266 in the month prior and the same month in the previous year respectively. Regarding the appropriateness of creatinine orders, in the two months of our intervention compared to the previous weeks, we saw a steady decrease in inappropriate creatinine orders from 0.44/patient to 0.12/patient.

CONCLUSIONS The multifaceted QI intervention resulted in significant decreases in the burden of lab testing, inappropriate creatinine and urea orders, and a shift to ordering CBC without differentials which are generally more appropriate for routine testing

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University of Alberta Hospital (UAH) Standardizing GI On Call Redsident Handover AUTHOR NAMES: Dr. Lindsey Russell SUPERVISOR/SPONSOR NAME(S): P. Mathura, D. Baumgart, A. Kohansal INTRODUCTION: Handover is an essential aspect of patient care. It is an opportunity to update the on call residents on outstanding tasks and sick patients. Structured handover has been studied in a wide variety of health care settings, and SBAR format was found to be effective. This format includes Situation, Background on the patient, Assessment and Recommendations or the plan going forward.

At the University of Alberta, SBAR is a handover format that all Internal Medicine Residents are trained on at the beginning of residency. However, the lack of a structured handover during the Gastroenterology rotation, has been an issue. Surveyed residents stated that handover did not occur 44% of the time on call and the quality of handover was good only 75% of the time. In addition, 94% of residents found that their stress levels on GI call were high and 84% of residents attributed handover to their stress levels.

The aim of this QI Project was to implement a structured format for handover from staff/residents to the on call resident. We also gave SBAR teaching templates for GI Residents to give effective handover to each other, which is an essential skill residents need. Our aim was to increase the handover frequency by 50%, increase the effectiveness of handover by 30% and improve the quality of information given through handover.

METHODS: The Model for Improvement provided the quality framework. Surveys were primarily used to gauge baseline qualitative data from residentsâ&#x20AC;&#x2122; perspectives on handover pre and post intervention. The intervention included an orientation on algorithms and SBAR training given to all residents at start of residency. The intervention was presented and approved by consensus by all GI Attendingâ&#x20AC;&#x2122;s in the divisional meeting. Audit sheets were completed each day to gauge handover and quality. Surveys post implementation were used to assess residentsâ&#x20AC;&#x2122; perspectives of handover.

RESULTS: Overall we found the biggest gap was no set time or place for handover. Throughout the project we chose unit 5C4 at 16:30 to have handover with staff. We had an orientation for residents to educate them on when and where the handover will be as well as tips for handover, such as printing off a Netcare list, and writing to do lists.

A total of 51 days were audited, and handover occurred a total of 83% of the time. The handover was further subdivided in whether both ward teams provided handover, that occurred 65% of the time and 17% only one team provided the handover. Of the 17% of days where there was no handover, it was all during weekend days. With surveying the post intervention group, we found that handover improved to happening 83% of the time. In addition, the quality of the handover was rated good 83.3% of the time and 66.6% of residents found that they received all the necessary information. Interestingly stress levels of GI call were still high at 100% and 83.3% of residents attributed handover to their stress levels.

CONCLUSIONS: Handover is an essential aspect of patient care and being on call as a resident. We found that standardizing handover for a certain time and place increased the amount of handover given by 27% and the quality increased by 8.3%. We found that encouraging handover during the weekend was the largest challenge and the stress levels of GI residents were unchanged with the implementation of more handover.

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Targeting Incomplete Bowel Preparations for Inpatient Colonoscopies AUTHOR NAMES:

L. Russell, A. Lee, H. Rempel, D. Perez, G. Noel, M. Mohamed, P. D’Souza, D. Baumgart, S. Van Zaten, R. Sultanian, S. Zepeda-Gomez, B. Halloran, N. Kassam, P. Mathura, and A. Kohansal

SUPERVISOR/SPONSOR NAME(S): AHS Quality Innovation Fund, Vessie Heckbert Memorial Summer Research Award and Physician Learning Program INTRODUCTION At the University of Alberta Hospital (UAH), patients admitted to the gastroenterology wards may require an urgent colonoscopy for diagnosis and treatment. The bowel prep process includes drinking a laxative prior to the colonoscopy, to clean out the colon. However, the quality of these bowel preps is complicated by factors such as poor taste, large volume and medical comorbidities. In turn, poor bowel preps can result in less visibility during colonoscopy resulting in poorer health outcomes, repeat procedures, higher health care costs, and diminished patient experience.

The number of incomplete colonoscopies due to poor bowel prep for inpatients on the gastroenterology wards at the UAH is a concern, recorded at 6% by the endoscopy unit and approximately 20% from a qualitative GI physician survey. The aim from this quality improvement (QI) project was decrease the number of incomplete inpatient colonoscopies at the UAH by 30% over 2.5 months.

METHODS The Model for Improvement provided the quality framework. An interdisciplinary team that perform inpatient bowel preps completed numerous QI tools to identify opportunities for change in the inpatient bowel prep process, and developed interventions targeting these gaps. Plan-Do-Study-Act (PDSA) cycles were carried out to test and analyze the impact of the interventions.

RESULTS Numerous gaps were identified as possibly contributing to the rate of poor inpatient bowel preps, including bowel prep order variability, timing, education, lack of tracking, poor tolerance of prep, and lack of communication between units. The interventions implemented to address these gaps included a standard bowel prep order label, an instructional patient job aid, and a ‘tip sheet’ for nursing staff containing strategies for when a patient is not tolerating the prep. PDSA cycles demonstrated a reduction of incomplete colonoscopies over 2.5 months, as well as a 59% rate of use of the standardized label, 70% rate of standard bowel prep education, and 100% rate of education for residents and registered nurses when on service. Patients were satisfied with the bowel placement, with 59% found that the placement would help with future preparations and 84% would self-track amount of prep taken. All of the Residents surveyed would use a sticker if readily available and 88% found it easy to use. Finally, all of the Nurses surveyed found the Nursing Tip sheet helpful and 89% of nurses knew what to do if the patient was having a hard time with the bowel prep.

CONCLUSIONS It is possible to reduce the number of poor inpatient bowel preps and the educational tools developed with this project helped residents, patient and nurses with the bowel prep process. It is anticipated that the interventions developed here can be easily adopted by other units that have less experience with prepping patients. By doing so, we can improve patient experience and health outcomes.

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Enhancing Physician Engagement and Leadership in Health System Transformation AUTHOR NAMES: S. Marini SUPERVISOR/SPONSOR NAME(S): N Kassam, P Mathura and N. McMurtry INTRODUCTION: This action research project created an opportunity to engage physicians through dialogue and conversation about the key factors that impact their engagement in health system transformation. It explored more deeply why physicians engage and the barriers that limit their engagement from both a personal, professional and organizational context. The project addressed the research question: How can the University of Alberta (UA) Department of Medicine (DoM) enhance physician engagement and leadership in health system improvement?

METHODS: This multi-method inquiry engaged participants, through semi-structured interviews and a world café session, to identify their attitudes, beliefs, experiences and perceptions related to physician engagement. It was anticipated that through cycles of exploration, reflection and action, change would naturally occur as research progressed (Rowe, Graf, Agger-Gupta, Piggot-Irvine, and Harris, 2013).

RESULTS: During the data analysis, six distinctive themes emerged, including the larger theme of organizational culture to enhance physician engagement and leadership.

1.

Physician engagement is influenced by personal motivation and experience.

2.

Promote understanding and respect between physicians and organizational leaders by recognizing the different perspectives about work priorities.

3.

Provide physician stakeholders with the information required to make an informed decision early in the engagement process.

4.

Effective communication processes need to be transparent and shared openly and honestly.

5.

Provide continuous support, development and leadership training skills for physicians at all levels.

CONCLUSIONS: The following recommendations are intended to assist the DoM in its commitment to enhance physician engagement and leadership to “provide better care to all Albertans” (Calder Bateman, Department of Medicine Strategic Plan, 2014) 1: Creation of a culture of physician engagement that clarifies roles and behaviors needs to be developed and integrate into organizational and leadership plans.

2: Create the expectation and opportunity for physician engagement and develop a framework to support this expectation within the DoM. 3: Develop a physician engagement and leadership communication plan that embodies inquiry, dialogue and innovation.

4: Physician engagement and leadership needs to be lifelong and integrated into medical and professional education to develop physicians as leaders.

5: Creation of an incentive program that recognizes physician in performance and promotion.

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ACKNOWLEDGEMENTS

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

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