Shoulder Care ClinicDr. J. AmesDr. D. MackeyDr. P. Van ZylDr. S. ChuiLes Smith, Reg. OTIdowu Koledoye, RPTRobin Roots, RPTShelley Movold, RD

We have no disclosures.

Background

τWaitlistsτ Literature and experienceτ Imagingτ Best care for patients

Aim Statementsτ To reduce the T1 time (Referral to seeing a Doctor) of

patients waiting to see an Orthopedic Surgeon in PrinceGeorge by 50% or more by September 2019.

τ To reduce the amount of unnecessary imagingdone on shoulders in Prince George by 50% ormore by September 2019.

Team Members/Partnerships

τ Orthopedic Surgeonsτ Sport Medicine Physician (SMP)τ Physiotherapistτ Radiologistτ Northern Healthτ UBC Faculty of Medicine,

Northern Medical Programτ UBC Department of Physical Therapy, Northern &

Rural Cohort

SMP assesses patient(can consult with team where necessary)

NonsurgicalStream Surgical Stream

Patient is triaged to nextavailable surgeon

Medical Interventions(i.e. injections) Physiotherapy

Follow-up

FailureSuccess

Measurementτ #s conservative management & #s surgicalτ #s failed conservativeτ Shoulder function (patient self report)τWait timesτ Appropriate referral for imagingτ Family Physicians’ satisfaction with

the service

Outcomes/Next Steps

τ Early days, but…..τ Referrals began rolling in right awayτ Northern Doctor’s Day –large turnout of interest

from family physician’s to “A Morning ofOrthopedics”’; hopefully start of a CME tradition

τ NDD began with a review course on shoulderproblems, followed by information about theservice

Crossing Silos

τ Developed by multiple Specialists (SportMedicine, Orthopedics, Radiology,Physiotherapy)

τ Provides better care for patients (one stopshopping)

τ Continuing to build on these partnerships

Value of Physician QualityImprovement (PQI)

τ First PQI project for most of the physicians andphysiotherapists

τ Many silos to overcome, teamwork to accomplish andcrucial conversation to have

τ The infrastructure of PQI kept us going and allowed us toovercome hurdles

τ Much thanks owed to everyone on the team andespecially our PQI team lead, Shelley Movold

WORKINGACROSS

SILOS

DR JESSICA OTTE, CCFPNANAIMO REGIONAL GENERAL HOSPITAL

PQI COHORT #1, ISLAND HEALTH

* I have no financial/commercial conflicts of interest to declare* I am faculty/employee of UBC Medicine, and have received honoraria from Doctors of BC for committee work

MAKE DISCHARGE SUMMARIES GREAT AGAIN!

Disclosure

Presenter / Faculty Dr Jessica Otte

Relationships with commercial interests:

Grants / Research Support None

Speakers Bureau/Honoraria None

Consulting Fees None

Other None

AIM: “To increase the rates of documentation of a correct medication list forcomplex, adult patients discharged from Nanaimo Regional General Hospital(NRGH) by internists and hospitalists to 100% in 6 months (by June 2017)”

OR , if unable: sheer determination

CLINICIAN // ADMINISTRATION

COMMON GOALS(PQI FUNDING)

FINDING THE RIGHT PERSON

BEING PERSISTENT

FINDING THE RIGHT PERSON

PQI TEAM // “THE SYSTEM”

BEING PERSISTENT

FINDING THE RIGHT PERSON

NANAIMO // VICTORIA

COMMON GOALS

COMMUNITY // ACUTE CAREGP // SPECIALIST

BEING PERSISTENTCOMMON GOALS

ACCEPTING IMPERFECTION

OR , if unable: sheer determination

DR JESSICA OTTE, CCFPNANAIMO REGIONAL GENERAL HOSPITAL

PQI COHORT #1, ISLAND HEALTH

MAKE DISCHARGE SUMMARIES GREAT AGAIN!

With thanks to:- Dr Ian Bekker- Kristie McDonald- Suzanne Beyrodt-Blyt- Curtis Bilson

Jessica.Otte@viha.ca

Triage to improve experience of patientsand families referred for palliativeradiotherapyMichael McKenzie MD, FRCPC (Radiation Oncology)BC Cancer/PHSA PQI Cohort #1

Disclosure

• Relationships with commercial interests:– Member of Steering Committee, Local Principal Investigator ATLAS

Study, Janssen Research and Development

• Material presented unrelated to financialrelationships with commercial entity

VARA Clinic-Same day consult andpalliative radiation therapy

• For patients, receiving treatment on the sameday as their consult can save unnecessary travel

• For administrative staff, same day treatmentreduces phone calls to patients and the need tocoordinate multiple appointments

• However, inefficiencies noted:– Wasted treatment slots:– Patient barriers to care:

Current State Analysis

• Approaches were used to understand the gapsin care:– Tracking of missed appointments– Individual meetings with team members:

• Manager, Clinical Operations• Nurses at the VARA clinic• Booking clerk• DTES nurse and Patient engagement staff

– Multi-stakeholder Meeting

Tracking of Treatment Cancellations

• Jasbir Dhanda, RT clerk, tracked cancellationof treatment appointments at VARA fromJanuary 3 to April 14, 2017

VARA Clinic Treatment Appointments

Total number ofappointments

58

Total number ofcancellations

19

Percent of apptscancelled

33%

Major Feedback from StakeholderMeetings

• Patient needs not known at time of appointment– Patient may be too sick to undergo treatment (e.g.

need to be first treated for pleural effusion before thept can undergo treatment)

– Patient is poorly functioning, e.g. patient may not bemobile

– Cannot plan for other work that will need to be done:e.g. arrange homecare, palliative care benefits, etc.

– Need for RN support is not identified– Correct site for RT not included on requisition

Major Feedback from StakeholderMeetings

• Interpreters for appointment• Patient symptoms not managed• Appointments with nurses run overtime• Treatment cancelled because tests pending• Difficulty contacting DTES• No Goals of Care discussion• Patient and family education lacking

Planned PDSA Cycles

• Development of Triage Checklist• Pilot of Checklist in small number of patients• Pilot of Checklist in all Tuesday AM VARA

patients• Consider implementation in all patients referred

to BC Cancer for palliative radiotherapy

Thank you!

Team PHSA PQI:– Bethina Abrahams– Celine Kim– Judy Wang– Sandra Chow– Chiso Isato

Establishing New Pain ManagementPathway for Hip Fracture Patients at

St. Paul’s Hospital

Trina Montemurro, MD, FRCPC

Dept of AnesthesiologyNovember 19, 2018

No Disclosures

Background

• Hip Fracture Patient– Frail, complex– High-risk– High in-hospital

mortality

• Pain⇓ opioids• Booked for O.R. and

wait…• Delirious and obtunded

Background

• Regional anesthesia– Femoral nerve or fascia-

iliaca block– Less pain⇓ less opioid

consumption

• PHC Dept of Anesthesia– Many trained in US-

guided regionalanesthesia

Photo courtesy of usra.ca

Aim Statement

• To improve the pre-operative painmanagement of hip fracture patients at St.Paul’s Hospital

– Establish a pathway where patients receive anerve block for hip fractures as soon as they arediagnosed

The Team – The Stakeholders

• Anesthesiologists– Regional anesthesia

team– Perioperative team

• Emergency Medicine• Orthopedic Surgery• The ward• Internal Medicine• Acute Pain Service

PDSA Cycles

Develop a newpain pathwaythrough PDSAcycles – in progress

ihub.scot

Crossing Silos

Physician Quality Improvement (PQI)Rapid Fire: Physician Engagement – FE and PQI Working Together

Dr. Raj Johal

Family Physician – White Rock, BC

ER to Primary Care Communication project

November 19th, 2018

Disclosure

2

Presenter / Faculty Dr. Raj Johal

Relationships with commercial interests:

Grants / Research Support None

Speakers Bureau/ Honoraria None

Consulting Fees None

Other None

Managing Potential Bias

2

Not Applicable

QI Project Background

3

Setting• Peace Arch Hospital• Primary Care clinics

Issue• Quality of Primary care follow• ER Repeat visits

Potential solution• Improvement of ER to Primary Care

communication

Project Team

3

• Community Family Physicians

• ER Physician

• ER Nursing and administration staff

• Information Technology Department

Aim Statement

3

• Reduce repeat ER visits of those patients previously seen within 10days, by 25% over the course of 10 months.

PDSA Cycles

3

• Plan - Draft paper based ER to PC communication tool

• Do - Implement communication tool with small group of patients

• Study - Evaluate usage and feedback from the communication tool

• Act - Revised communication tool to reflect the feedback

PDSA Cycles Contd.

3

• Plan - Use pre-existing electronic communication tool in hospital EMR

• Do - Trial of this EMR communication feature with one ER doctor

• Study - Evaluate effectiveness of EMR communication tool and PCfeedback

• Act - Expand use of EMR communication tool to other ER staff

Outcome, Next Steps

3

• Variable results• Reduction in repeat ER visits – but not sustained

• Next steps• Ongoing data collection

• Further evaluation of Balancing measures• Primary Care workload• 30 day ER revisit rates

• Further Process measures• Rate of EMR communication tool usage

My PQI Experience

3

Strengths• Motivated health care providers• No shortage of great ideas• Opportunity for improvement

Challenges• No structured method for QI• Time commitment• Working in silos

Crossing Silos

3

• Silo #1• ER/Hospital

• Silo #2• Primary Care

• Silo #3• Patients

Dr. Raj Johal

Manraj.johal@alumni.ubc.ca

QUESTIONS / CONTACT