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Physicians Lead the Way to Hospital at Home

Physicians Lead the Way to Hospital at Home

Victoria Hospitalists Dr. Elisabeth Crisci and Dr. Shauna Tierney have been unwavering in their pursuit of a new kind of care for patients. Now, their passion project is about to become a reality with the BC Government’s launch of Hospital at Home across the province.

With Hospital at Home (HaH), acutely ill adult patients who are at lower risk and have a predictable clinical path can get hospital-level care from a team of professionals at home, safely and effectively. The model has been used for years in countries like Australia and the UK.

Extensive studies, including three Cochrane reviews (Ref 1), show that HaH provides equivalent or better clinical outcomes than standard hospitalization. Length of stay tends to be shorter and there is a higher level of satisfaction amongst patients, their caregivers and healthcare workers. It also shields patients from some of the complications associated with a brick and mortar hospital stay.

Dr. Crisci first saw HaH in action several years ago while doing fellowship training in Australia.  “This was not home and community care. It was acute, hospital-level care: IV medications, blood transfusions, oxygen. There is no doubt in my mind that those patients, if they were back in Canada, would need to be on a hospital ward.”

“A hospital is an unsettling environment, especially for frail and elderly patients,” she says. “I thought, ‘why can’t we do the same in Canada?’ The expertise and therapies that we associate with hospital care are all portable, and so is the hospital staff.”

“It is an opportunity to offer safer, more patient-centered care for our patients and for less cost. It is the right thing to do.”

Back in Canada, she often thought about the HaH model. Then, in 2019, an opportunity came up to take action. Her Hospitalist colleague, Dr. Shauna Tierney, was reading about a HaH program for COPD and was inspired. 

“I saw that we could do better for our patients’ dignity and comfort, and thought, “we have a moral imperative to do this." - Dr. Shauna Tierney

Dr. Tierney reached out to Island Health and her Hospitalist colleagues to see what could be done. Dr. Crisci was ready. “We knew that we needed to join forces to make this happen.”

Left: Dr Elisabeth Crisci.  Right: Dr Shauna Tierney

Collaboration moves the vision forward

The two physicians would need help to develop a HaH program for BC– including the buy-in and support of the Island Health, South Island Hospitalists, the Divisions of Family Practice, and eventually, the Ministry of Health. Funding from Health System Redesign and Facility Engagement made that possible.  

“Over the past year we worked relentlessly to get the level of engagement this project requires, while developing our own HaH program for B.C.” says Dr. Tierney.  It meant that they had to become agents of change, inspire others to think outside of the box, and challenge some old-standing beliefs about how hospital-care can be delivered.  

“The same old thinking will always give you the same old results,” says Dr. Crisci.  “We argue that what should define hospital-level or acute-care is the type of patient and the type of clinical interventions required, rather that adhering to a definition based on the physical location of the patient.”

Taking the hospital team and interventions to the patient's home would require further support, which they sought from the BC Ministry of Health. “We don’t want this to be just another community-based service,” says Dr. Crisci.

“We want a true substitute to a standard hospital admission. For this to be possible, we have to ensure that these patients fall under the governance of the provincial Hospital Act. This means that even if at home, these patients are admitted and under the responsibility of the hospital.”

To their delight, the Ministry was interested in doing much more with HaH, and in September 2020, announced that BC would introduce the model to Victoria, and then spread it across the province.  In part, HaH can help with the government’s COVID-19 planning by freeing up some acute care capacity.

Next steps

While there are details to iron out to pilot HaH at Victoria General Hospital and eventually scale to other hospitals, a full-time project team is in place to take the work over the finish line.  The doctors are continuing as medical leads.

They note that experienced physicians on the ground are uniquely positioned to bring innovative ideas such as this to the fore. But they could not have done it alone. It took everyone’s help to make their vision a reality.

“It has been quite an adventure. It started with two physicians with an idea, and now HaH is one of the priorities for BC’s health care system,” says Dr. Tierney.
     
“The collaborative effort between the Ministry, Island Health and the front-line physicians has been incredible; something I never thought I’d ever witness in my career,” agrees Dr. Crisci. “Here we are, side-by-side, to not only improve the care of patients but also working to make our system a bit more sustainable.”    
    

"I can’t wait to see that first patient’s face when I can say, “you get to go home, and I will come to see you at home.” - Dr. Elisabeth Crisci


Funding for physician engagement in the HaH project was provided by Health System Redesign (HSR), an initiative of the Joint Collaborative Committees (JCCs) – a partnership of Doctors of BC and the Government of BC – and the South Island Medical Staff Association, funded through the South Island Facility Engagement Society and Specialist Services Committee (one of the four JCCs).

See the South Island MSA website for background, rollout and BC Government plans for Hospital at Home>   

 

Ref 1: Cochrane Reviews

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007491.pub2/full

https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000356.pub4/full

 

 

 

 

     

 

What's happening

Engaging Physicians to Improve BC Health Care

"Facility Engagement in Action" highlights a few examples of the hundreds of successful activities across BC that are making a difference.   Read it here >

2020 Facility Engagement (FE) Evaluation Survey

2020 Facility Engagement (FE) Evaluation Survey

Facility Engagement is currently undertaking province-wide evaluation. Physicians/medical staff and health authority stakeholders are invited to take our survey to help us evaluate the value and impact of the FEI.  Click here to participate by August 31!

Coronavirus (COVID-19) Updates

Facility Engagement: What is changing?

What is changing?
A lot has changed in the four years since the Specialist Services Committee launched Facility Engagement across BC to strengthen meaningful physician involvement in health authority decision-making. 
  • Across BC’s acute care facilities and programs, 72 Medical Staff Associations (MSAs) in 6 health authorities have galvanized more than 4,300 physicians to participate in 2600+ Facility Engagement activities. (Updated to February 2020).
     
  • A combination of new structures, funding, physician leadership, and administrative supports are enabling MSAs and their physician members to improve engagement and teamwork among colleagues and with health authorities, in ways that were not possible in the past.
     
  • The UBC evaluation of Facility Engagement to March 2019 found that medical staff and health authority leaders think that participation in the initiative is worthwhile.

With all of this activity  – and a lot of hard work  – a sense of optimism is fueling a growing culture of engagement across BC, with renewed teamwork and positive experiences reported by many of those involved.

Big themes: Foundation for change

“This is an exercise in relationships – setting a foundation that allows us to grow as an organization, as people, as a team, as partners in care.” – Dr. Harsh Hundal,  Executive Medical Director Physician Engagement & Resource Planning, Interior Health

  • Physician-to-physician communication and relationships are improving as a key step for MSAs to build a strong foundation for engagement and a medical staff voice. Physicians are connecting and meeting across sites and regions – for the first time ever in some cases – to get to know and support each other, discuss priorities and work on projects that strengthen their hospital, patient care, and personal well-being. 

  • Communication with health authorities is improving. At many sites, MSA working groups and physician members are regularly meeting and establishing collaborative processes with health authority administrators and leaders to discuss respective priorities, and to work on projects together. 

  • Physician wellness has also surfaced as a priority, with MSAs across BC initiating activities that aim to reduce the risk of burnout and support physicians to provide patient care in a healthier way.  Some MSAs are now starting to elevate these efforts to an organizational, regional and system level to look at potential improvements that can reduce the risk of burnout. (Doctors of BC is further working on this priority through the Physician Burdens engagement and policy development process.)

  • ​With the new 2019 Physician Master Agreement, Facility Engagement is also officially supporting medical staff engagement in the implementation of electronic health records, starting with Lower Mainland hospitals that are adopting the Cerner syste

Moving Forward

There is more work to be done to achieve sustained change, and further evaluation of the Facility Engagement Initiative will to measure its ongoing impact. Meanwhile, both physicians and health authority partners from many parts of the province report they are making headway to build trust and to make decisions together that impact their hospitals, programs, work culture and patient services.  Stay tuned as this great work continues to unfold!

Read examples and successes > www.facilityengagement.ca/stories

Facility Engagement in Action

Courage and community come together to improve surgical quality and safety

Dr Michel Hjelkrem, an orthopedic surgeon at Kootenay Boundary Regional Hospital took what some might consider drastic steps to reduce surgical site infections – he stopped doing joint replacements. Then his four partners joined him. For the next two and half months, they embarked on a mission to collaborate with their health authority to improve surgical standards. And while it wasn’t always an easy road, it turned out to be one of the best decisions they made to lower infection rates well below the national average.

Read the story here >

May 2019

Physicians Advocating for Wellness

Physician health is a common theme for MSAs, with 100+ wellness-related activities underway across BC. They range from group fitness to social opportunities, to relationship-building across medical disciplines, to tackling workplace and system frustrations. The engagement of physicians in a health care organization is, in itself, a key factor to reducing burnout.

The FE provincial team is looking at how to coordinate MSA physician wellness activities with other regional / provincial efforts including those of Doctors of BC.  As a start, new FE funding guidelines for physician wellness have been introduced to elevate physician health activities to a strategic level moving forward. Find them here under 'funding.'>

Meanwhile, last November, Fraser Health’s regional Medical Staff Wellness Committee welcomed 45 physician health champions from its 12 hospitals and 10 divisions, as well as health authority leadership, to brainstorm how Fraser Health could support and promote physician health.  As their ideas unfolded, the Committee realized that they were sowing the seeds for a regional Physician Health Program. Read about it here >

 

April 2019

Physicians: How are you interacting with your hospital and health authority?

Doctors of BC's annual Physician Health Authority Engagement survey is here!  BC physicians and specialists are invited to answer a 3-minute survey to provide important insights about how MSAs can advocate for physicians within our facilities and the community and to create and focus programs and policies to better support physician work with health authorities.

Anonymous. Confidential. Deadline: April 30, 2019.

  • To complete the survey, look for the invitation sent to your e-mail from Health Standards Organizationon April 1 with reminders thereafter. (Screenshot of invitation is below).  

Featured Story

Reconnect with meaning and purpose

Trusted expert and internationally recognized caregiver advocate for reducing clinician fatigue and improving employee engagement, Dr. Stephen Swensen,  Professor Emeritus, Mayo Clinic, met with members of the Vancouver Physician Staff Association this January. He shared lessons learned over his three-decade-long career with the Mayo Clinic.

“Many physicians are working in a state of professional distress,” stated Dr. Swensen. “This goes beyond burnout and includes PTSD, emotional exhaustion, clinical depression, moral injury, compassion fatigue, and suicidal thoughts. When you’re in this state, you’re more likely to make a medical error. You have relationship problems, addiction problems; your productivity goes down as does your level of quality of care. One of the biggest opportunities we have to improve patient care is by caring for each other.”

An ideal workplace has three elements that Dr. Swensen calls agency, coherence and camaraderie. The happiest teams at the Mayo Clinic, he said, have the agency to make decisions, feel connected to their group, and celebrate each other’s milestones.

Leadership behaviours

Dr. Swensen identifies five behaviours (Leader Index Behaviours) that make for better leaders:

  1. They are inclusive.
  2. They communicate transparently.
  3. They value your ideas.
  4. They are interested in your career.
  5. They appreciate your work.

Mayo Clinic staff are surveyed annually on how their leaders rate in these areas. Those with low scores are coached to improve these or are moved out of leadership roles because leaders who don’t exhibit these five behaviours are causing harm to patients.

Medicine is a calling

Some people go to work every day for the paycheque; others see their career as a means to accomplish goals and receive acknowledgement of their contributions. It is common for those who choose a career in health care to also see their work as a calling, as a means of helping patients, their families and the greater community. When that sense of purpose is lost, said Dr. Swensen, physicians can develop professional distress.

“Engagement is the antipode to burnout; it connects us to meaning and purpose,” he said. “The number one driver of happiness is meaningful work so you would think health care should have the lowest rate of burnout. But sometimes we lose sight and have to be reconnected to our purpose. Coherence can do that. Coherence exists when all parts of the system fit together to form a united whole.”

To create coherence, leaders need to ask, listen and empower.

“It’s that annoying pebble in your shoe that holds you back rather than the mountain you need to climb. The research is clear that when departments work together to identify the ‘pebble’ they reduce burnout. You can apply this to Cerner. Superusers could monitor who’s using the system on weeknights and weekends and then ask them if they need assistance. A superuser can save a physician three to five hours a day by teaching them shortcuts.”

Architects rather than carpenters

The pronouns we use when we talk about our organization are a clue to how well that organization is thriving. When we think in terms of ‘us’ and ‘them’ rather than ‘we’ and ‘our,’ the institution flounders.

“If physicians are treated as partners, they behave that way,” said Dr. Swensen, who recalled how the Mayo’s chair of haematology addressed her team’s high burnout rate.

“She decided to be a leader, a champion—rather than a middle manager. Instead of saying this is what they’re telling us to do, let’s all just be carpenters, she empowered her physicians to be architects. They weren’t going to be told how to do something by people who don’t understand what they do. The team created the solutions.”

When we do our work, improve our work, and care for each other, our patients have the best doctors imaginable. Lean into tomorrow, Dr. Swensen encouraged, to see what difference you can make.

Further reading: Finding and Creating Joy in Work white paper (IHI white paper, co-authored by Dr. Swensen)

 
Thank you to the Vancouver Physician Staff Association (VPSA) for sharing this article and photos. >

 

 

 

   

 

 

Facility Engagement Update

Saving the Elk Valley Hospital Operating Room

Little did they know that the retirement of their only general surgeon at Elk Valley Hospital (EVH) in Fernie would bring about a significant opportunity for collaboration with both the physicians in the neighboring community and their Interior Health partner.

                                                   

Having no luck with recruiting a new specialist surgeon for the hospital, despite a strong partnership with local governments to assist the recruitment efforts, physicians and staff started thinking about what could be done to save the OR. After all, this retirement could mean that surgical services in Elk Valley Hospital would have to close down and over 15,000 residents in Fernie, Elkford, Sparwood, Elko, and Jaffray would have to travel as much as 170 km to the nearest hospital in Cranbrook both for consultations and surgeries. Road conditions during the winter could make it even more challenging for patients to receive surgical care, especially for pregnant mothers requiring a C-section. Increased pressure on hospital staff and resources in Cranbrook from the additional elective day surgeries could also lead to longer wait times in that community.

In order to identify a solution that would save and sustain the OR in Fernie and not destabilize OR services in Cranbrook, physicians came together through funding from Facility Engagement to create a Surgical Sustainability Committee. The committee included representation from the physicians and Interior Health Authority (IHA) including the Chief of Staff, Health Services Administrator, Health Services Director, Site Manager, Medical Administrative Assistant, and Patient Care Coordinator (head nurse).

The solution conceived was both creative and sustainable, and involved the engagement of all parties. First, a Family Practitioner with Enhanced Surgical Skills (FPESS) was recruited to regain a slate of elective day surgeries in Fernie. However, as the FPESS was not starting for 12 months, the committee reached out to the Surgical Unit at East Kootenay Regional Hospital in Cranbrook, the neighboring city, to discuss an opportunity for them to perform surgeries at Elk Valley Hospital - with a goal of meeting patient needs closer to home while creating an opportunity to add sustainability to both surgical programs.

Through one-on-one personal phone calls made by committee members, specialist physicians in Cranbrook were able to discuss the opportunity and express their interest formally. EVH Physicians attended a Surgical Leadership meeting in Cranbrook to present the opportunity at their rural facility, and build their relationship with the Surgical Specialists.
 
Cranbrook surgeons were provided with all relevant information for working at Elk Valley Hospital, including the OR schedule of open days, an offer to have Fernie nurses travel to Cranbrook for a day to observe the surgeons’ working styles to build mutual comfort levels, and coverage of travel costs for surgeons through Northern and Isolation Assistance Outreach Program (NITAOP).

In addition, an examination room was secured at Elk Valley Hospital for patient consults and equipped with furniture, donated local artwork, a fridge, and a nespresso machine to serve as a comfortable ‘home away from home’ for visiting surgeons as a model consultation space and a comfortable private space to take breaks between surgeries.

On the first day of work, Elk Valley Hospital staff and physicians came together for lunch sponsored by Facility Engagement to welcome and meet the visiting surgeons. Jacqueline Arling, the Facility Engagement Project Manager for Elk Valley Hospital, believes that the key to this solution was relationship building. “A big factor for the surgical sustainability success is that physicians have built trust and relationship with both the Cranbrook physicians and Interior Health.”

The residents of the Elk Valley now have four visiting general surgeons conducting consults and surgery at the Elk Valley Hospital, in addition to the current GPs and soon-to- start FPESS physician. The surgeons are proud of being able to help a neighboring community in need of specialist care. Taking collaboration to yet another level, these surgeons can also help mentor the local FPESS to expand their capabilities to perform surgeries in Fernie.

Reflecting on the success in Fernie, Karyn Morash, Health Services Director said, “With the advent of Divisions of Family Practice and Facility Engagement the way physicians were coming to the table was changing, it facilitated our ability to work more closely together.”  while noting that “to the health authority’s credit, we have worked with determination to honor our part of the commitment to engagement with MSAs.”

Given the historical communication challenges that existed between health authorities and facility-based physicians, Elk Valley Hospital is a perfect case example of solution finding made possible through collaborative efforts leading in turn to improved patient care--the ultimate goal of the physicians, health authority and the Facility Engagement Initiative. 

Physician, heal thyself recommends Dr. Himat Vaghadia

                    

In 2010, longtime VGH anesthesiologist Dr. Himat Vaghadia was working over 50 hours a week and was not paying attention to what his body was telling him. He had low energy, daily pain, poor sleep and was gaining weight. Read the full story here

Facility Engagement Funding Guidelines

One theme expressed by MSAs both at the March mid-term site review meeting and through the recent interim UBC evaluation is the need for clarification around the MOU funding criteria. Supplementary funding guidelines were recently approved at the June meeting of the SSC Facility Engagement Working Group (FEWG). Over the next 6 to 12 months, the FE team will monitor feedback from the HAs and MSAs over the use of the guidelines and report back to the SSC FEWG on any substantive input and/or recommended changes. Read the full guidelines here.

Facility Engagement Provincial Evaluation

A team of researchers from UBC has come together to evaluate the Facility Engagement Initiative and the implementation of the Memorandum of Understanding on Regional and Local Engagement (MOU).  The provincial evaluation will:

•    take place from now to early 2019;
•    provide real time feedback about the implementation of the initiative which can be used for immediate improvements;
•    gather evidence to understand and measure the success of Facility Engagement activities; and
•    provide accountability to all stakeholders.

Physician societies and health authorities will receive a package of information shortly outlining when and how to participate in the provincial evaluation.  Read more here >

Alcohol Policy

The Ministry of Health has advised that any funding provided via the Physician Master Agreement cannot be used to purchase alcohol. This covers all collaborative funding including SSC Facility Engagement funding for Medical Staff Associations’ (MSAs) operations and activities. Read the full policy here.

Private Vehicle Mileage Reimbursement Policy

Doctors of BC has recently changed its policy regarding the use of private vehicles for work travel, and we would like to communicate this update to all sites. It is recommended that MSAs/physician societies follow these guidelines to provide consistency as they develop their own policies around private vehicle travel reimbursement.

The Doctors of BC reimbursement rate matches the Ministry rate and is pre-set in FEMS (e.g., $0.53/km).

 
What is FESC?

 

Facility Engagement Services Company (FESC) is a new legal entity for unincorporated MSAs (smaller sites) to manage funds and contracts, and limit liability risk for MSA executives. FESC will support your MSA with regards to cost-effectiveness, local autonomy, reporting, managing and sessional claims as well as funding and accountability. Your Facility Engagement Liaison (FEL) will discuss this new structure with you.

New Facility Engagement Sites

As the Facility Engagement Initiative is growing, so are the number of sites working with us. Congratulations to the seven sites approved for full FE funding in 2018 so far. The number of fully funded sites has now reached to 59!

  • Arrow Lakes Hospital
  • Dr. Helmcken Memorial Hospital
  • Nicola Valley Hospital and Health Centre              
  • Prince Rupert Regional Hospital
  • R.W. Large Memorial Hospital   
  • Sechelt Hospital               
  • St. John Hospital
Data Driven Improvement Workshop

“The Data-Driven Improvements workshops held by the BC Patient and Safety Quality Council provided attendees with practical and applicable strategies to drive healthcare program improvements. Content included effectively identifying indicators, efficient data collection, and practical analysis techniques. This is a great workshop for those seeking to achieve project goals and assess project success.” – Workshop Attendee

Click here for upcoming workshop dates.

FEMS Quick Tips

                                   

With Delta Hospital and North Island Hospital Comox Valley now fully operational in FEMS, we’re so pleased to announce that our onboarding of all 27 incorporated physicians societies is complete. With over 2500 members, FEMS has processed over $6M worth of claims for the Facility Engagement Initiative.

Our next step is to bring the MSAs that are not incorporated on board. This will take place in the fall, with regional training sessions and refreshers being offered around the province by Maria Chessari, our new FEMS Project Coordinator.  We have taken this opportunity to include a few improvements to this release version:

  • Updated column titles and button names
  • Grids and filters with improved functionality
  • More user friendly reports generator allowing for detailed reporting on multiple levels.

If you have any questions or concerns about the changes, please reach out to our team at FEMS Support by contacting us at femssupport@doctorsofbc.ca, 604-638-4869, or 1-800-665-2262. 

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