Concurrent session III: Community and culture in learning health systems

Thursday, March 8, 1:30 – 2:30 pm
Salon F
Chair: Michael Law, UBC Centre for Health Services and Policy Research

The PREFeR (PRioritiEs For Research) Project: Patient priorities for primary care research in BC

Presenting author: Louisa Edwards, Simon Fraser University Faculty of Health Sciences

Co-authors: Melody Monro, Hayley Pelletier, Yaron Butterfield, Brenda Jagroop, Regina Cid, Kent Cadogan Loftsgard, Sabrina T. Wong, Ruth Lavergne

Objectives: Primary care is where most patients first consult for health needs. Primary care research often focuses on understanding patient needs and gaps in care, but patients are infrequently included in prioritizing research ideas. Patient and clinician priorities may significantly differ. PREFeR (PRioritiEs For Research) aims to identify patient-generated priorities for primary care research in British Columbia, comparing patient and clinician perspectives.

Methods: Framed by the Dialogue Model and employing Nominal Groups Technique, a patient advisory group explored experiences of primary care. Patients reviewed, discussed, and individually ranked the topics that emerged. Online surveys were administered province-wide to capture patient and primary care provider ratings of importance of the top 10 topics. Overall and between-group (e.g., rural-urban) importance ratings were compared and linear regressions tested socio-demographic predictors of topic importance. Rapid literature reviews evaluated research hits within a Canadian and provincial context. A final dialogue event will bring patients and clinicians together to share the survey and review results, identifying areas of agreement and disagreement.

Results: The 10 members recruited to the patient advisory provided over 80 experiences of ‘what stood out’ in BC primary care, which were grouped thematically into 18 topics. Amongst the top 10 ranked topics, patient-centred care, information sharing/electronic medical records, and lack of regular provider scored highly. Preliminary survey results of patient and provider priorities overall and by socio-demographic groups will be forthcoming. Findings from rapid literature reviews indicate variability in the extent of research amongst the 10 topics within Canada and BC.

Conclusion: Involving patients in primary care research priority setting is important to patients, feasible, and fruitful. Ultimately, this benefits the intended end-users, leading to more efficient and effective health care system. Patient-identified priorities are broad themes that future projects could develop into specific research questions. Topic importance, patient-provider alignment, and under-researched areas are key considerations.

Developing a research-informed organizational model for dementia care in a learning healthcare system

Presenting author: Margaret Saari, Saint Elizabeth Health Care and University of Waterloo

Co-authors: Marina Bastawrous Wasilewski, Paul Holyoke, Justine Giosa

Learning healthcare systems align research, informatics, incentives and culture to create an environment of continuous improvement and innovation where best practices are embedded in the care delivery process and new knowledge about the care experience is collected and analyzed to inform future care. As Canada’s largest social enterprise, Saint Elizabeth is dedicated to fostering a collaborative culture of innovation and learning in the design, delivery and evaluation of health and social care services. As a learning health system, Saint Elizabeth has made a strategic investment of 13 million dollars over 13 years for research to improve people’s health and care. Researchers in the Saint Elizabeth Research Centre work closely with the clinical, business, education and innovation departments and stakeholders of the organization to support action-oriented, evidence-informed decision-making in health and social care.

In recent years, due to concerns related to quality of care, appropriate resource utilization and overall health system sustainability, research and policy interest in dementia care has seen a sharp increase. Accordingly, research describing and testing models of dementia care has increased steadily over the past ten years. Various models of care for individuals with dementia across the health care continuum have been developed and implemented. Some of these models are proprietary and may require significant investment on behalf of organizations choosing to implement. In 2017 senior leadership at Saint Elizabeth requested a summary of existing models of dementia care in order to inform decision-making about “the Saint Elizabeth model” or approach to non-medical care for persons living with dementia and their caregivers living at home and in long-term supported arrangements. The Saint Elizabeth Research Centre translated this request into a scoping review project with the following broad research questions: What models of dementia care can be identified in the existing research literature? This presentation will discuss the process used to distill the vast amount of research evidence identified into a useable format for organizational decision-makers. Key considerations for, and challenges encountered in, knowledge synthesis and dissemination will be discussed in the context of developing a model which spans healthcare settings and levels.

Increasing physician engagement at the hospital level: Evaluating a BC initiative

Presenting author: Chris Lovato, UBC School of Population and Public Health

Co-authors: Neale Smith, Graham Shaw, Asif Raza Khowaja, Jean-Louis Denis, Craig Mitton

Objectives: Physician engagement is an essential element of learning healthcare systems; engagement is key in improving patient care, patient safety and physicians’ working environment. In support of this, British Columbia’s (BC) Ministry of Health (MoH), Doctors of BC, and the province’s health authorities launched a province-wide initiative to increase physician engagement within acute care facilities. This study –an external, independent evaluation — aims to assess processes, outcomes, and costs relative to benefit during implementation of this Facility Engagement Initiative (FEI).

Methods: The evaluation is employing a mixed-method approach. Qualitative data are collected through document review, natural observations, in-depth interviews or focus groups with stakeholders and participants including physicians, facility administrators/managers, facilitators employed to assist with the initiative, and MoH officials. Quantitative data are collected through cross-sectional surveys, a dedicated project management system, and secondary data analysis.

Results: Interim evaluation of the FEI is based upon implementation of the initiative through December 2017. Key results to date include the following. Participants noted that the expected start-up process was complex, particularly for smaller hospitals, and required skills not typical of physicians. Consequently, the support provided to sites through Doctors of BC was highly valued. Once sites completed their start-up, locally hired project managers appear to be important for success. The Initiative’s commitment that sites could determine for themselves the barriers to physician engagement and relevant strategies to address these was valued, though greater cross-site sharing of experiences and lessons was desired. Much of the early stages involve efforts at conscious relationship-building (a key form of organizational work identified in the literature).

Conclusions: At the approximate midpoint of implementation, progress towards FEI objectives is being made. Concerns about physician engagement appear to vary in nature between large and small sites, as do approaches towards addressing them. There is overall stakeholder support for the Initiative to date. On-going improvements to the process are being made as the FEI rolls out to additional sites across the province. The final evaluation will be reported in 2019.

Engage, educate and empower: A three step approach to create a culture of learning in Vancouver General Hospital Emergency Department

Presenting author: Parm Hari, Vancouver Coastal Health Authority

Co-author: Nikita Nabh

Vancouver General Hospital Emergency Department has the largest headcount of employees (200 employees) compared to 8 other hospitals under Vancouver Coastal Health. In 2015/16, the turnover rate was 32%, and the sick rate was very high at 5.7%, which was impacting workflow efficiency and workload. The workplace environment was stressful due to difficult and sometimes aggressive patient interactions. Staff did not have anyone to approach to talk about such incidents. This impacted engagement and resulted in low staff morale. In February 2016, the Healthy Workplace Initiative (now ‘Culture Initiative’) was launched to transform the workplace culture using a 3 step approach:

  1. Engage: A survey was conducted to identify main issues in the ED. Some major issues that emerged were: lack of physical and psychological safety, no leadership support and not enough knowledge on violence prevention and effective management of critical incidents. Visioning exercises and weekend retreats were held for staff and physicians to engage and to foster team building. A new leadership structure with DC3 nurses was introduced to make leaders more accessible and provide coaching and support to staff. Working groups were created with nurses and physicians leading them.
  2. Educate: Coaching was provided to ED leadership and physicians on developing conflict resolution skills and improving team interactions. Weekly just in time violence prevention exercises were launched by OH &S. Timely critical incident stress management group debriefings were organized by EFAP to ensure that the team witnessing such incidents is provided with support and information about stress management and coping strategies.
  3. Empower: A peer mentor group was created (includes physicians) which in its second year, has doubled in membership. Every shift has at least one peer mentor who is the go to person for any or any issues or concerns that staff have on shift. The group was trained in and now trains new mentors in emotional intelligence, respectful workplace, informal leadership, difficult conversations and managing critical incident debriefs.
    Staff engagement now is very high and turnover rate has decreased by 79% since 2014/15.

Lessons learned: Frontline employees and physicians need to be empowered to lead and create a culture of learning and continuous improvement.