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Physician-led engagement results in a clean air solution in PFT

Physician-led engagement results in a clean air solution in PFT Lab

Left to right: Dr Heather Clark, Repirologist, Carmen McClymont, Senior Respiratory Therapist, Jodi Zimmer, Supervisor, Respiratory Ambulatory Programs - with the  Ambius air filtration unit.

Like many older hospitals, the Royal Jubilee Hospital (RJH) in Victoria has clinical spaces that began as patient rooms. The Pulmonary Function Testing (PFT) Lab is located in such a space. When COVID hit, the lab was challenged:  how do you conduct PFT when patients can’t wear masks and the room is not properly ventilated?

During the first couple of months of COVID, the lab remained closed, except for emergencies. Then the Canadian Thoracic Society came out with regulations for the safe resumption of lung function testing.

To meet these regulations, PFT at RJH resumed on a limited basis. A room had to be closed down for three hours between each patient to ensure any airborne viruses had settled.

Dr Heather Clark, a respirologist and the medical director who oversees PFT knew they needed a better, long-term solution.

Facility Engagement funding

A Facility Engagement (FE) project looking at patients with long COVID symptoms accelerated a solution. Lung testing was part of this FE project. “In talking with a colleague who was requesting these tests and explaining our issue – he suggested I apply to FE for funding to help us," says Dr Clark.

Dr Clark successfully applied for FE project funding to improve the air exchange in the PFT lab, which consisted of three rooms. “Applying for funding turned out to be easy. Clara Rubincam, FE Project Manager was a great help," she notes. "Physicians are so busy – I’d like them to know it is easy to apply for the funding, and there is a lot of guidance and assistance available.”

Engaging stakeholders in solutions

Dr Clark began by gathering a group of relevant stakeholders, such as PFT lab supervisors, ambulatory care administrator, facility maintenance to participate in a number of Zoom meetings. The meetings helped solidify a solution, which initially would have involved renovating each of the three testing rooms over a period of three to four years.

Cross-site knowledge sharing

Dr Clark connected with a colleague at Providence Health Care and asked him what they were doing to address the aerosolization of viruses and air exchanges. It turns out they were looking at other technologies, such as air filtration.

 “He connected me with the facility maintenance manager at Providence and their pulmonary diagnostics coordinator, and I introduced them to our facility maintenance person. The air filtration units became the right solution. Rather than air exchanges, they now have air filtration, filtering the air through HEPA and carbon filters to achieve the equivalent cleaning of the air."

Project support

Part of Dr Clark’s success was due to Charlotte Bowey, an Island Health administrative assistant who was working on her Master’s Degree in project management, who scheduled the meetings, attended and took notes. “She was crucial to my success," says Dr Clark. "She knew who I should involve. She also knew just when to send out meeting notes to keep everyone engaged.”

 “I’m pleased we solved the problem and I wouldn’t be losing sleep at night. My patients are compromised, often they are on immuno-suppressors and I need these tests to know if the therapies are working and how to adjust them if they are not.”

Solutions save costs

One advantage to this project is having the Providence Health Care solution already evaluated and approved before an investment was made at RJH. In addition, the cost savings are quite significant. Initially, $100,000 was earmarked to renovate one room. In the end, the costs for the health authority for air filtration systems for all three rooms were about $45,000.

Dr Clark’s adds an observation about obtaining FE funding. “I didn’t understand that it could be applied to this project – I thought it would have to be more directly tied to patients. I think it’s important to let physicians know that it is not difficult and that people want you to succeed.”

 

 

Physicians take the lead to establish provincial PAS clinic

Engaging to support patients with Placenta Accreta Spectrum

For about 20 years, the Royal Columbian Hospital (RCH) was the unofficial referral centre to help treat Placenta Accreta Spectrum (PAS), a serious pregnancy condition that occurs when blood vessels and other parts of the placenta grow too deeply into the uterine wall.

During delivery, a PAS patient may experience an average blood loss of about two to three litres with a need for a transfusion of up to 4-1/2 units of packed cells. There’s an 85% chance of a hysterectomy and a 50% chance of urological injury to the ureter or bladder.

In 2020, Dr Sara Houlihan, an obstetrics and gynecology surgeon at RCH applied for funding from Facility Engagement (FE) to help establish RCH as the provincial PAS Clinic.

“There is extensive research supporting this excellence of care model to reduce serious complications and deaths.” - Dr Sara Houlihan

Multi-disciplinary engagement

Dr Houlihan engaged a small multi-disciplinary team to collaborate on overlapping processes such as ultrasounds, iron infusions, surgical interventions, and so on. “

There are so many wheels to put in motion when a patient gets referred to us,” says Dr Houlihan.

Clinic and website

The multi-disciplinary PAS Clinic is now officially open, along with a PAS Clinic website, which is available to both care providers and the public. The website educates about the condition and provides referral forms to access services.

"We have reduced blood loss and decreased transfusion rates; we’ve reduced length of hospital stays – which is amazing for patient care." 

Timely detection and risk factors

Timely management of this condition is imperative. The condition is often first detected on an ultrasound, usually at 22 or 28 weeks. Dr Houlihan notes, “it is a devastating condition that can have major ramifications for patients and the quality of their lives.”

If a radiologist suspects there is an abnormal placenta during a routine ultrasound – they suggest a referral and evaluation to the primary care physician, who can then refer the patient to the PAS clinic.

There are also risk factors that can pre-dispose a patient to have PAS, such as prior C-sections (the more C-sections, the greater the risk), placenta privia (placenta overlying the cervix) and any previous uterine surgery.

These pre-existing conditions can trigger a referral, which is why the PAS Clinic is working to raise awareness about these risk factors with care providers.

Why Royal Columbian?

Dr Houlihan talks about why RCH is uniquely qualified. “To be a centre of excellence you must have obstetrics ultrasound technicians who has experience in PAS, you need a capacity to do MRIs and radiologists who have experience in PAS, a level three maternity and nursery, ICU, obstetrical anesthesiologists, transfusion medicine and specialized surgical teams," she notes.

"Our biggest ace are our maternal fetal medicine sonographers. They are the ones who do the ultrasound, determine risk levels and triage for appropriate care."

“We are consultants on this issue – so the primary care provider continues the prenatal care – we stratify the patients’ risk with imaging, optimize patients with referrals to specialists and sub-specialists, and for high risk patients, we perform their surgery at RCH.”

Awareness and education

Education is important – so Dr Houlihan and her team are spreading the word about the PAS Clinic and its resources through discussions with the Obstetrical Societies in BC. For family physicians, plans are in the works to do in person education sessions. In addition, all the information has been uploaded to Pathways, which includes referral forms and patient handouts.

Progress and looking ahead

The long-term goal for the PAS Clinic is to navigate PAS patients through every step of their journey, including comprehensive after care that would address both the physical and psychological impacts of this condition.

Asked what she is most proud of, Dr Houlihan said, “I’m happy about the gains we have made in patients’ outcomes – we know we have reduced blood loss and decreased transfusion rates; we’ve reduced length of hospital stays – which is amazing for patient care.

"We all want to provide excellence in maternity care and everything we have been doing has made a positive difference.”

 

Working toward cultural safety and cultural humility in the ED

Working toward Cultural Safety and Cultural Humility in the ED

Prince George Medical Staff Physician Association, University Hospital of Northern BC

In 2021, the EQUIP Health Care research project conducted in three BC emergency departments including in Prince George, shared findings on health inequity issues that affect Indigenous people and others seeking care. It shone a light on opportunities for change in emergency departments, often the first point of entry for many people accessing medical care and inpatient treatments, and when patients are at their most vulnerable.

The University Hospital of Northern BC (UHNBC) in Prince George is in a unique position to help create long-term and sustainable approaches to address these issues. It is the largest teaching hospital in Northern BC for health care providers of the future, and is located in the region with the highest Indigenous population in the province.

At the same time, the work of the Prince George Medical Staff Physician Association (PGMSPA) is a collaborative and integral part of helping to build toward equitable and culturally safe care.

Catalyst for change

A foundation for change was established in 2018 when Dr Terri Aldred[1] pioneered the PGMSPA’s Cultural Safety and Humility work (currently led by Dr Todd Alec). In 2019, ER physician Dr Christina Boucher began to lead the cultural safety and humility work in the Emergency Department (ED). Dr Boucher is a non-Indigenous person who seeks to be an ally and advocate for issues of inequity in health care delivery concerning Indigenous people. 

With PGMSPA Facility Engagement funding to cover physician time, she took several steps to get started. She first spoke with Dr Aldred about her vision. “Dr Aldred told me about her group, the identified need for physician peer support in the ED. This foundational work helped guide me in developing my ED work.”

Dr Boucher reviewed the EQUIP research project to better understand specific health equity issues in the ED. She also gained insights from In Plain Sight "Addressing Indigenous-specific Racism and Discrimination in B.C. Health Care" that reported on issues of inequitable health care access and outcomes endured by Indigenous peoples in BC in health care settings.

Dr Boucher then connected to work being done in Northern Health to incorporate into planning, including initiatives and resources offered by Northern Health’s Indigenous Health team to support learning and self-reflective practice among all physicians and employees.

Building an inclusive working group with Indigenous voices

In order to foster and sustain change, full representation of all vested voices was needed to source and articulate issues and work together on solutions.Dr Boucher assembled a collaborative, diverse working group (see below) representative of virtually all interdisciplinary positions working in the ED. 

Most importantly, the group needed to include Indigenous community members who rely on the ED and have lived experience as Indigenous people, whose participation required having trusted voices from the Indigenous community engaged in the work.   

Through Dr Montana Halliday, Dr Boucher reached out to Lucy Duncan, an Elder working at the Central Interior Native Health Society and a well-known member of the Indigenous Prince George community. Lucy has also contributed to the EQUIP Health Care work, which seeks to ensure health equity within BC’s health care system.  

Lucy joined the working group as an Elder and also spread the word to Indigenous community members to add their voices, particularly patients who experienced care in the hospital ED.

WORKING GROUP

  • Elder, Central Interior Native Health Society
  • 2 MSA physicians
  • Northern Health staff: ED Program Leads (x2), Social Worker, ED Nurse, Acting ED Manager
  • Indigenous Psychiatry Resident
  • Indigenous patient
  • Indigenous artist
  • College of New Caledonia Aboriginal Resource Centre representative
  • Former Chief, Stellat’en
  • Elder Teacher, Lheidli T’enneh
  • Aboriginal Patient Liaison
  • Central Interior Native Health Services, Nurse Health Care Coordinator
  • University of Northern BC / EQUIP researcher / Nurse Practitioner

"I was excited to join and expand on the work I’ve been doing with other health providers. It’s important to understand historical racism and its impact, if we want to build a better health care system that serves everyone. 

...It is important to have Elders from the community with lived experiences as part of the group," she notes. "It is through their participation that open communication can happen about what Indigenous people want to experience in the ED and what barriers they have faced.” - Lucy Duncan

Feeling and finding purpose through truth telling and relationship building

The group agreed to meet monthly, and to start their work by creating an authentic foundation for change through relationship building and storytelling. The meetings place an emphasis on connection before content. Meetings start with introductions and check-ins, followed by open space for Elders and Indigenous community members to talk and share.

She emphasizes the importance of truth-telling to build understanding and support for action to address Indigenous-specific inequities in care. “The challenge is to be sure you are working on the real issues that will make culturally significant change – so it’s important to verify with the community."

"I have learned this year from the Elders on our group that relationships and trust are foundational, and are the most important activity when coming together as a group." - Dr Christina Boucher 

Between meetings, Dr Boucher spends a lot of time checking in with each working group member about thoughts and feelings that have come up in the meetings. She notes that each person reacts differently, as personal, emotional stories are shared.

In her experience, she finds that talking about cultural safety and cultural humility can be challenging on a social and emotional level. It is a personal journey that takes time, and trust, and cannot be rushed."

It takes time to work through emotional contexts in order to even feel safe with one another, let alone to talk about all the details and processes involved in making the environment safe for all.

From there, the group can start to formulate action items that have arisen from the discussions.

"I see the activities of the working group prompting people in our department to engage in the self-reflective process of developing cultural humility.

Space and time are needed to build trust, create understanding, and shift beliefs to create sustainable change.“  - Dr Christina Boucher 

Changing mindsets leading to positive change

The First Nations Health Authority's "Creating a Climate for Change" describes cultural humility as "a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a learner when it comes to understanding another’s experience." 

Dr Boucher uses this sentiment to approach thinking about practical steps to take as a health care provider: “As a non-Indigenous person, I try to approach the world with an open curiosity. I hope to be an ally and advocate for the Indigenous people who are my patients, and my patients’ family members."

"I hope to continue working on identifying my personal biases and the systemic barriers that contribute to the inequity of care the Indigenous people have historically received, to make some positive improvements.” 

Asked how this work could be expanded to other communities, Lucy Duncan says,“we need to build credibility with other communities by initiating the working group’s recommendations, such as an Indigenous Patient Liaison working in the ED, and showing the positive changes happening in Prince George.”

She hopes to one day see a health care system that puts aside personal biases, and provides care in a safe environment that includes dignity and respect. 

"It is only through acknowledging our past can we move forward to a better future."  - Lucy Duncan

Taking action: building blocks for change

Discussions have led to the following action items:

  • Plans to redesign the ED space to be more inviting to the Indigenous community, for example working with a local artist to create drums and relevant artwork.

  • Advocating with Northern Health for an ED-specific Indigenous Patient Liaison position who would assist indigenous patients to navigate through the ED and access care.

  • A proposal for cultural safety training for the security company working in the ED.

  • Using video monitors in the ED to display information about community resources and supports.

  • Sharing culturally significant learnings from the monthly meetings with ED doctors and nurses, as well as community urgent care clinics and physicians in other Northern Health hospitals and communities.

[1] Dr Terri-Leigh Aldred is the Medical Director for Primary Care for the First Nations Health Authority. She is leading community-based First Nations Primary Care Initiatives (FNPCI), as well as the First Nations Virtual Doctor of the Day (VDOD) and First Nations Virtual Substance Use and Psychiatry Services (VSUPS) to engage medical affairs matters related to our programs.

This work has been supported with funding from the Specialist Services Committee Facility Engagement Initiative, one of four joint initiatives of Doctors of BC and the Government of BC.

 

 

 

Introduction of traditional foods to hospital connects patients with culture

Creating patient-centered and culturally safe care

At Northern Haida Gwaii Hospital in Masset, the introduction of locally-prepared and sourced traditional Haida foods to the hospital menu connected happy and grateful patients to their culture. In addition to increased patient satisfaction, the improvements in food quality also reduced costs by 20%.

In 2018, the Medical Staff Association and registered dietitian Tessie Harris embarked on a Facility Engagement project to restore on-site hospital food preparation, with a plan to integrate local and traditional foods.Haida Gwaii is home to the territory of the Haida Nation, where wild and traditional foods are abundant and an important part of the culture.

Prior to this project, the hospital had been serving retherm meals made elsewhere, delivered in individual portion sizes, and reheated for patients. There were patient complaints and low food satisfaction in surveys.

Serving up change

Although a small hospital serving 8 or 9 patients and residents, some big steps were needed to prepare meals on site. 

To start, Tessie Harris liaised with Northern Health’s regional diet office in Prince George to align and coordinate the food service transition with Northern Health guidelines and processes. The site adopted the regional menu while incorporating traditional foods to reflect the needs and wishes of patients and respect local culture.

Staff then started cooking one meal a week on site, increasing the frequency over time. By the end of one year, they were cooking all of the patient meals in the Northern Haida Gwaii Hospital and Health Centre kitchen.

Traditional Haida foods were incorporated into the menu. Wild berries and greens were locally sourced. Arrangements were made with fishers in the area to catch salmon and halibut to be processed by local plants. They wanted support the hospital and patients, who were often their friends, family or neighbours.

Patients were happy and grateful. They commented about how much the food connected them to their families, culture and memories. They started eating more, and the amount of food returned to kitchen decreased.

Notably, while increasing the quality of the food – but without increasing staff levels – the site saw an approximately 20% reduction in food costs.

The success of the food service transition project has helped to influence a broader effort that continues in Haida Gwaii to integrate local and traditional foods into other areas of the community, and build capacity for a local, sustainable food system.

In our small rural hospital, improving quality of food served by resuming in-house cooking has had noticeably improved staff and patient morale. We are serving food that we want to eat!”
— Dr Caroline Walker, MSA President & Chief of Staff,  Northern Haida Gwaii Hospital

Dietitians at the hospital continue to work with the community and Northern Health to increase the amount of local and traditional foods offered, an effort that reflects the greater focus within health care to provide patient-centered and culturally safe care.

"Patients light up when you serve food that reflects their culture. Nutrition is a big part of it, but the emotional, cultural and spiritual health and feeling of being connected is also making a difference.”
­—    Tessie Harris, Project Lead

Building a Sustainable QI Network at BC Children’s Hospital

Building a Sustainable QI Network at BC Children’s Hospital

Three pediatric physicians at the BC Children’s Hospital have a long-term vision to create a BC Pediatric Quality Improvement Practitioners (BCPQIP) Network. It brings physicians who have an interest in QI together on a regular basis to network with QI colleagues, share knowledge, receive guidance/advise and help further spread QI work.

Drs Tiffany Wong, Mia Remington and Sandesh Shivananda have all participated in QI in various ways, including through SSC’s Physician Quality Improvement (PQI) program.

Although there was a lot of QI work being done in the hospital – much of it was siloed. “We came together in a very organic way,” Dr Wong says. “Mia and I met through PQI and we met Sandesh through his work with the Hudson scholarship program, which is a program that allows junior physician scholars to focus on quality improvement one day a week over a two-year period.”

.  .       

Left to right: Drs Tiffany Wong, Mia Remington and Sandesh Shivananda

Moving from silos to collaboration

Drs Wong, Remington and Shivananda acting as co-chairs began to build the network with funding from SSC’s Facility Engagement Initiative and Health System Redesign. They reached out to Quality Leads within each hospital division, physicians who have participated in PQI, Hudson scholars and others who expressed an interest in QI. Dr Remington notes, “We conducted a needs assessment survey before our first meeting because we didn’t believe the three of us should be setting the direction – it’s a shared experience.”

The survey responses helped to guide their first meeting in October 2020. There were about 27 physicians who all weighed ideas, expressed opinions and helped set priorities. Of course, all of this work was happening at the height of the pandemic, so Zoom meetings were core to furthering the development of the network.

Learnings from the survey and first meeting found that physicians wanted regular quarterly 90-minute meetings to share and receive feedback from QI colleagues on their projects, hear from QI experts and create partnerships for the spread of QI work across hospital programs. Physicians also wanted to foster engagement with the Health Authority (HA) Leaders and create a QI centre of excellence with ongoing operational funding. The co-chairs then prioritized their next steps.

The initial intention was to have the FE funding pay for speakers and some meetings held in a semi-formal atmosphere for face-to-face and network opportunities – but pandemic restrictions eliminated this approach. Two of the co-chairs went to the Institute for Healthcare Improvement (IHI) Annual conference in 2020 and identified some outside speakers, who they invited to present to the BCPQIP network. There have now been regular quarterly meetings held all through 2021 on Zoom with full attendance. 

Dr Claire Seaton joined the network and says, “working in QI lends itself to collaboration, learning from others’ successes and failures, and getting feedback. The network gives us a space to do this, and has supported our efforts to be recognized for our work.  I’m grateful to be a part of it.”  

“We had a couple of HA Leaders invited to our meetings including Dr Felicia Lang, who is a Quality Lead within the health authority," Dr Remington notes. "She spoke to our group around quality structures – so it was a good opportunity to get to know each other.”

The next meeting is in April and for the first time it is planned to be a face-to-face dinner meeting with the goal of setting their direction for the coming year. Health Authority Lead Dr Derek Human is scheduled to share his experiences in QI, and also help members identify HA quality improvement initiatives that could be of interest to them.

“We don’t pay anyone to come to our events and they still come. I think they see value in being connected with like-minded colleagues,” he observes. “I think that is really powerful and valuable in itself.”

Success factors: connections, relationships

The co-chairs agree that to be successful you need to really use your network, identify champions, and make meetings valuable so people want to attend.  

Dr Shivananda notes, “We started this journey by nurturing connections and relationships between members. One of the challenges faced by our physician leaders is maintaining enthusiasm in driving change. Validation and appreciation of their efforts by peers helps everyone be resilient and remain engaged.”

Since the network has been established there have been a number of diverse QI projects presented and discussed, including a multi-disciplinary approach to asthma education, prescription medication equity and a parenteral nutrition program.

In addition, Dr Wong worked with the Faculty of Medicine DARPT committee to develop a promotions package where a doctor could be promoted based on QI work from Clinical Instructor right up to Full Professor.  

“We developed a package with the DARPT committee and presented it to the pediatrics department,” she said. “They liked it so much they brought it to the Faculty of Medicine. After some revisions, it has been formally accepted. I’m very proud that health quality improvement, systems innovation and patient safety work is now formally recognized as important academic work.”

QI work will continue to be integral to delivering quality patient care and the BCPQIP Network is laying the groundwork for sustainable QI improvements in BC. Dr Shivananda is optimistic about the future. “We hope to strengthen the infrastructure for spread and scalability of innovative practices across the campus and beyond."

This work has been supported with funding from the Specialist Services Committee Facility Engagement Initiative and Health System Redesign. Both are joint initiatives of Doctors of BC and the Government of BC.

 

Emergency simulation 'undoubtedly saved lives' during heat dome

Crisis reinforces the value of regularly simulating events

When the ‘heat dome’ descended recently onto British Columbia, many emergency departments were flooded with patients suffering from a dangerous condition known as hyperthermia. 

Fortunately, Victoria-based Emergency Department (ED) physicians had run a hyperthermia scenario a year prior through its ED Simulation initiative, and identified important gaps in care that could be remediated. These included having ready access to cooled-IV fluids, body bags that could be filled with ice and water to further cool patients, and fans for misting.

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Finding common ground

Collaboration increasing between VPSA physicians and their health authority

Every month leaders from the 1,900-member Vancouver Physician Staff Authority (VPSA) and Vancouver Coastal Health (VCH) sit down to talk over mutual issues. They come to each meeting with an intentional focus that was agreed to by both groups and they rotate who chairs the meeting between VCH Interim President and CEO Vivian Eliopoulos and VPSA Managing Director Dr. York Hsiang.  There is lots to talk about; both see physician wellness as a priority and they are also both invested in ensuring diversity, equity and inclusion among medical staff, and—for the past year—quickly communicating news regarding COVID-19.

VCH Physician Wellness Steering Committee

Since its start, VPSA has intentionally focused a large part of its work on wellness. In 2019, the health authority suggested combining forces to assess the level of burnout amongst physicians, to find its causes, and to develop collaborative solutions. The VCH Physician Wellness Steering Committee was formed with five health authority representatives and 12 VPSA members.

“We quickly realized we needed to understand what drives physician burnout and how that is different in every department,” said committee co-chair Dr. Zafrina Poonja. “We surveyed members in late 2020 and are now reviewing the data.”

Dr. Poonja credits the interdisciplinary composition of the committee with its ability to move the issues of physician wellness forward.

“We each bring a different perspective and it’s been important to have the support of VCH leadership. The health authority is invested in this issue and wants to do more so we can all be well; they’ve been very supportive. There are no quick fixes; there are issues within our system and within health care that are long standing. But if we can target micro interventions there could be a domino effect. It will take a lot of time and many grassroots initiatives, but my participation on this committee has made me hopeful.”

Communicating unexpected outcomes

Not all medical procedures go as intended and it is often left to physicians to deliver distressing news. It is therefore vital that physicians know how to communicate unanticipated results in a sensitive manner. VCH reached out to VPSA for help with this as it is a concern for both physicians and the health authority. VPSA funded a select group of skilled physicians to attend Communication of Unanticipated Outcomes in Healthcare training in fall 2020, thus developing an inhouse group of experts who will now teach the course to other physicians and health-care teams across the region.

“Partnering with VPSA on this project was paramount to ensuring physician engagement and collaboration,” said VCH Regional Director, Patient Experience Elizabeth Baron. “As we learn more about how to better include physicians as a part of our health-care teams and represent a cohesive approach to communicating with patients and families, we hope to see improved experiences for everyone. The impact of improved disclosure conversations—in addition to it being the right thing to do—has been shown to build trust in the organization, reduce fear of blame, decrease litigation against providers and the organization, and also shed light on organizational opportunities for improvement.”

“This project was a great example of recognizing a problem common to both physicians and the health authority, developing a response, and enacting solutions,” added Dr. Hsiang. “The educational leadership we’re creating will lead to improved communication skills that will ultimately benefit patients and their families.”

Later this year, the physician trainers will begin training their colleagues in communicating unanticipated medical outcomes.

Improving equity and inclusion in medical leadership

In January 2019, VPSA hosted an appreciative inquiry into meaningful leadership experiences and opportunities for women physicians. That work inspired the creation of the VCH Medical Staff Diversity, Equity and Inclusion (DEI) initiative. Eleven physician members sit on the committee along with four VCH medical leaders. The group’s work has earned praise from top VCH leadership including its board and interim president and it has changed the way VCH recruits medical leaders.

Over the past year, the committee held focus groups with women physicians about their experiences during the pandemic and it developed and launched a diversity survey to all VCH medical staff. It is about to begin physician Indigenous, Black and People of Colour focus groups and is planning an International Women’s Day event on gender equity in medicine.

“World events have made an impact on our work and there is broad interest in seeing DEI issues move forward at VCH,” commented committee member Dr. Joy Masuhara. “The health authority has started an organization-wide strategy and has valued getting physician input and feedback. We’ve taken a very co-creative approach and I feel that participating on the committee has helped foster better relationships between our groups. VCH is a large, complex organization and I have a better understanding now of the broader context for this work.”

“Without support from the VPSA committee members, the ability to influence a culture of change within the medical staff would be more challenging,” added VCH Manager of Physician Engagement Neli Remo. “The VPSA members have demonstrated courage and commitment to propel the DEI work to organization-wide levels and they continue to work tirelessly to advance and co-create an inclusive workplace.”

Welcoming new physicians to VCH

VPSA regularly hosts Meet and Greet events for onboarding physicians; its September 2020 event was held virtually via Zoom.

“Over 100 physicians joined our association in 2020 and we felt it was especially important to make them feel part of a community,” said Dr. Hsiang. “The pandemic has isolated us more than ever and we believe it is critical that we continue to take steps to break down silos between departments and divisions.”

VCH senior leaders attend these onboarding events and offer welcoming words. At the February 2019 event, Vivian Eliopoulos made these remarks:

“Our organization is our house and we need to have open and honest conversations about how we can make it the best possible place to be. There are discussions happening today that didn’t exist in a coordinated way before VPSA was formed and there’s a palpable energy encouraging us all to connect, collaborate and care. But [VCH leaders] can’t fix what we don’t know is broken. We want to hear from you so we can partner to make improvements.”

VPSA and VCH are now collaborating to survey newer staff to get a sense of what their pain points are in the onboarding process. The data will be used to craft solutions and improve their experience.

Communicating during a pandemic

There’s nothing like a common enemy to bring people closer together. A silver lining of COVID-19 has been the co-operation that it has brought about between groups like VCH and VPSA.

“We knew we would need to provide physicians with information about the virus that the hospital would be too busy to communicate,” said Dr. Vivian Yin. She and Dr. Sophia Park, who were both VPSA board members at the time, pulled information from the BCCDC and WHO websites and started a WhatsApp forum that touched on many COVID-19-related issues.

“VCH leaders were paying attention to WhatsApp and were impressed with how we were moderating it; they asked us to help them with physician communication. It was a timely request as we quickly outgrew WhatsApp and transitioned to the Slack platform that VCH medical staff continue to use to this day. VCH took over the platform and VPSA continues to provide support.”

The Slack channel has had a tremendous impact on physician engagement with specialists from various departments and divisions sharing knowledge rather than working in silos. Bridges have been built and leaders have emerged; it has also created a sense of community.

Early in the pandemic, VCH offered all-staff townhalls to update workers on the impact of COVID-19 on its sites. However, the information that physicians needed was different from that of, for example, nurses. VCH medical leaders Drs. Patty Daly and Chad Kim Sing understood that perspective and were amenable to suggestions for forums specifically targeted to medical staff. COVID-19 Virtual Medical Staff Forums debuted in March 2020 and have run regularly. Vancouver Acute also started offering a regular VA update.

Drs. Yin and Park were instrumental in the forums’ early days. They worked out the logistics and made sure physicians’ questions were gathered ahead of time.

“We stressed that all questions needed to be answered—even if it was only to acknowledge that they didn’t have an answer,” remembered Dr. Yin. “It’s increased the health authority’s transparency and it’s been new territory for VCH, which isn’t used to sharing so much information.”

“Medical staff communications have been well received during COVID-19 and these medical staff forums are a part of that,” said Dr. Kim Sing. “These efforts have led to deeper and more meaningful engagement and we’ve been able to continually improve our dialogue and communication with and between our medical staff colleagues.”

There is interest in continuing the medical staff forums in the post-pandemic world. The format and frequency may change but, in Dr. Yin’s eyes, COVID-19 has opened the VCH leadership’s mindset to getting more physician input.

Vivian Eliopoulos agrees. “One of the positive things around the pandemic is the networking across the organization that has occurred and it’s something we certainly want to continue,” she said. “My hope is that our forums don’t stop. Eventually we’ll move away from talking about COVID and vaccine planning into other areas of interest for our physicians.”

 

Shifting paradigms

A physician’s learning of the Touchpoints approach helps nurture parent-child relationships

As a family physician working in a maternity clinic in Comox, Dr Theresa Wilson observes families interacting with each other and sometimes witnesses the frustrations related to adapting to a child’s development. This is an experience not unfamiliar to her during some of her visits with families with young children.

“All parents want to do well by their child, and all parents have strengths,” says Dr Wilson, who credits Touchpoints for her understanding that relationships are the foundation for development. 

Dr Wilson first learned about Touchpoints and attended the initial training when it was brought to the Comox Valley by the Pathways to Healing Partnership and a public health nursing coordinator.

Touchpoints is a framework that guides practitioners to intentionally build on relationships between physicians and parents and their families, and between parents and their young children.

Dr Wilson explains that using the Touchpoints guiding principles is a culturally responsive approach to care as it can help practitioners recognize and understand the differences of patients before and during a visit –meeting patients where they are at. Physicians can use the child’s behavior to learn more about where the family is at, and how they are coping with a new developmental change or challenge.  The Touchpoints principles also helps physicians observe interactions for strengths.

“You’re doing what you’re doing, just better. We are genuinely changing how we see people by becoming more self-aware,” says Dr Wilson.

Physicians can shift conversations between parents and children from what is not working to what is working well. Through reflection and practice, physicians work alongside families during predictable periods of disorganization or regression as a child learns or acquires a new skill or milestone.

“I can help parents to see that it’s okay that their child's development fluctuates when the child is working on a learning a new skill,” says Dr Wilson. “I can help normalize the ups-and-down.”

Strengthening the parent-child relationship

Dr Wilson recalls a time when she was with a patient who had just delivered her child. The patient’s partner had rushed into the patient room, missing the birth by eight minutes. Recognizing that the father was disappointed, Dr Wilson was able to help reframe the experience.

“I had seen the baby turn its head to look at the father when he came into the room,” shares Dr Wilson. “So I pointed that out to the father, who hadn’t seen it. I was able to use the language of the baby and narrate its behavior.”

By focusing on the positive aspects of the situation, Dr Wilson transformed how the interaction was remembered by the family.

Reducing physician burnout

By using the Touchpoints approach with patients, doctors can help reduce their own stress and feelings of burnout.

Before a patient visit, Dr Wilson reviews the area of development, looking for what might be seen or expected during the visit and reflecting on potential Touchpoints assumptions and guidelines. With that preparation, she feels grounded and ready for difficult issues that may come up during the interaction.

“My patients have commented about how they appreciate the extra time I’m spending with them, but that’s not the case,” says Dr Wilson. “My visit times have not changed.”

In 2018, Dr Wilson became a registered Touchpoints trainer in BC with the support of the Shared Care Committee (SSC) and Comox Valley Division of Family Practice.

Supported by the Physician Engagement Society of Comox and Courtney, which is funded by the Facility Engagement Initiative, the interactive training is offered to doctors through the Comox Valley Child Development Association (CVCDA). For more information, contact the CVCDA.

Watch the video below to learn more about Touchpoints from a panel of multidisciplinary health practitioners in BC.

The webinar is presented by the Shared Care Committee –one of four Joint Collaborative Committees that represent a partnership of Doctors of BC and BC Government– and the CVCDA.

Simulating emergencies bring invaluable results

In situ simulation helps save the life of a two-week old newborn

Any hospital’s Emergency Department (ED) has seen life-threatening drama and life-saving results – often it is preparation that makes the difference. Dr Matt Carere, an ED doctor at the Victoria General Hospital knows well the importance of being prepared.

During the past year or so, he along with Dr Donovan MacDonald, an emergency medicine resident doing a Fellowship in simulation training, with the support of ED Department Heads Drs Paul Collela and Gavin Jones, and help from the South Island Medical Staff Association's Facility Engagement Initiative funding have brought “in situ simulation” training to the hospital’s ED.

This training allows ED staff and relevant specialties to work, learn and reinforce their skills together in their clinical environment. It also helps identify hazards and deficiencies within clinical systems, the environment and the health team. This is unlike the traditional simulation training conducted at teaching hospitals.

From simulation to real life

A recent in situ simulation helped save the life of a two-week old newborn. Dr Carere, “there is nothing more daunting than having a two-week old premature baby in profound shock and peri-arrest come in. And nothing more satisfying than being able to work in the most efficient way possible to save her because we had just run a simulation a week previously that yielded a number of critical changes to our approach.” 

Over the last year, one to two simulations were held each month, involving not only Emergency Department physicians, but also Pediatric Intensive Care docs, PICU and NICU nurses, pediatricians, hematopathologists, anesthesiologists, adult intensivists, respiratory therapists, ECG and lab technicians, as well as more than 40 different emergency department nurses.

Dr Carere notes, “getting them to come in and give us their input on how we can improve our practices in the ED is invaluable. This doesn’t happen without complete buy in from everyone. In fact, we have a group of nurses who volunteer for these nursing education days. They’re getting examined under a microscope by us and they are all for it.”

“There is nothing more daunting than having a two-week old premature baby in profound shock and peri-arrest come in. And nothing more satisfying than being able to work in the most efficient way possible to save her because we had just run a simulation a week previously that yielded a number of critical changes to our approach.

Each scenario is attended by a clinical nurse educator to summarize the scenario and lessons learned to ensure any insights or needed actions are given to all ED staff. The group also film each simulation so that those not able to attend on the day can still learn from the experience. Dr Carere states, “It’s humbling because I’m in these rooms with all these talented doctors and nurses and every time I personally am learning so much.”

Due to COVID, some practices have been made more complicated. With in situ simulations, even the smallest barriers can be revealed to have a huge impact. For example, a recent simulation involved a cardiac arrest with a suspected COVID patient. One doctor discovered administering CPR in full PPE with glasses, googles and face mask left him unable to see as his glasses continually fogged up.

The South Island Medical Staff Association's FEI funding funding has been inestimable in allowing this work to happen. Feedback has been universally positive from staff to the hospital administration. Dr Carere is working to help make in situ simulation become a natural part of the hospital’s culture.

 

 

Maintaining physician wellness during Covid-19 and beyond

Maintaining physician wellness during Covid-19 and beyond

Doctors are working hard to provide the best care for their patients during the COVID-19 pandemic. These unprecedented times add stress and anxiety to physicians and frontline workers who may already feel burned out.

“I think most of us are just feeling tired,” shares Dr Laura Kelly, department head of Emergency Medicine at Ridge Meadows Hospital. “I'm seeing a fair amount of covert fatigue not just in doctors, but in all health care workers. A lot of people are exhausted.”

Dr Kelly and her colleague Dr Connie Ruffo, a White Rock hospitalist, recognized that doctors were potentially facing their own health crisis.

It’s why the doctors spearheaded swift efforts to prioritize the well-being of themselves and their colleagues through the Fraser Health Physician Wellness Committee, which is co-chaired by Drs Kelly and Ruffo.

As part of its work, the committee declared November as Physician Wellness Month in Fraser Health to keep health and well-being top of mind for all medical staff.

Also, the third annual Physician Wellness Forum held in November pivoted to accommodate pandemic restrictions, changing from an in-person event to a series of virtual workshops throughout the month.

Dr Kelly observed that the virtual sessions tried to accommodate both community- and hospital-based physician schedules, making it easier for doctors and medical staff to pop-in to the two-hour sessions at the end of workdays.

More than 100 doctors and medical staff joined weekly workshops to reflect on how to strengthen their personal wellbeing and of their colleagues. Topics included sources of wellness support, including community wellness teams, energy management, peer support, and compassionate leadership.

The forum is sponsored by the Fraser Health Authority and regional medical staff associations and divisions of family practice, and received funding for the first two years from Facility Engagement, an initiative of the Specialist Services Committee.

“The work we are doing for physician wellbeing highlights how vital Facility Engagement is in supporting physician partnerships with health authorities to nurture system change.”

Collaborating for cultural change

Dr Kelly notes that a doctor’s wellness is more than just caring for personal health through exercise, nutrition, or yoga. It’s also about connecting with peers to support one another. It is also about doctors engaging with the health care system to create changes that reduce the risk of burnout by improving efficiency and effectively delivering patient care.

For more than 15 years, Drs Kelly and Ruffo have been championing a shift in the culture of wellness at the grassroot level. They have been working with their peers, along with local and regional partners including MSAs, divisions, and Fraser Health. Together, these groups are fostering more peer-to-peer conversations, modelling compassionate leadership, reducing stigmas, and creating safe spaces.

In recent years, Drs Kelly and Ruffo have been working with colleagues and health care partners to develop a regional wellness strategy, visions and mission –a first of its kind in BC.

Recalling how she and Dr Ruffo got started, Dr Kelly says they modelled peer support by reaching out to colleagues who were distressed, sad or acting out, and fostered collegiality by hosting wellness activities where there were conversations about suicide, addiction, burnout, and how to look after a patient who's also a doctor.

Dr Kelly’s advice to other doctors is to do for themself and their colleagues as they would for their patients.

“It's just a matter of saying ‘I'm here. How are you? or I'm noticing this; how can I help?’”  

Dr Kelly says that simply taking the time to truly listen and hear a colleague is what peer support is about.

“If you have people in each community that are modelling peer support, then they are seen as advocates for their colleagues,” says Dr Kelly. “And then we have real movement in the culture shift that we're trying to make –that physicians are valued and supported.”

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