Qualitycast North

Drones, which are basically autonomous flying robots, have a variety of applications from controversial military operations to agriculture, cinematography, and package deliveries. Can this technology support improved healthcare services and healthcare equity in rural locations? Northern British Columbia comprises a vast geographical area the size of France, with a significantly smaller and dispersed population. Road links and municipal infrastructure to many of the smaller communities is limited and the harsh Canadian winters compound challenges to living during 6 months of the year. These challenges especially impact remote Indigenous communities, where accessing simple diagnostics or a pharmacy is greatly limited. These obstacles may seem intractable when it comes to providing healthcare, but rural physicians have responded by exploring the use of drone technology in their pursuit of healthcare equity. In this episode, we hear from Dr. John Pawlovich and project manager Sandy Lee about the UBC Drone Transport Initiative (DTI), an innovative project trialing the use of drone technology to improve geographic health equity in rural Northern BC that has developed in partnership between the Stellat’en First Nation, the Village of Fraser Lake, and the UBC Faculty of Medicine. Our guests share the joys of practicing and supporting medicine in rural and Indigenous communities, the importance and reward of community-led initiatives, and their love for living and working in the beautiful province of BC.

Today, the practice of modern medicine has changed and is now far more intense, complex and demanding of physicians than ever before. It may not come as a surprise to find, therefore, that physicians are now burning out at an ever increasing rate. The issue is one that often remains hidden or unrecognized but has implications for the resilience and sustainability of our healthcare system.

On todays episode we’re talking about Physician wellness and burnout, and the inspirational work local physicians are engaging in to tackle this growing issue. Dr. Ingrid Cosio is a family physician who has been practicing in Prince George for over 18 years. In addition to being an award-winning family doctor and providing medical leadership to the Northern Gender Clinic, in Summer 2022, she successfully applied on behalf of the PGMSA for the Physician Peer Support Pilot Project, a Physician Health Program initiative. The Prince George Physician Peer Support Program was created as a way to combat burnout and support the mental well-being of other physicians. She also shares her own strategies for self-care such as early morning running and the drawing from stoic philosophy.

It is well established that Indigenous peoples accessing the health system are subject to harm, and a lower quality of care. Many healthcare organisations are acknowledging this truth and making commitments to address systemic anti-Indigenous racism and improve cultural safety within the healthcare system. In this episode, we’re hearing from Northern Healths collaborative medical leads for Indigenous Health Drs Todd Alec and Sheona Mitchell-Foster. Dr. Alec is an Indigenous physician originally from Nak'azdli Whut'en, Beaver Clan. He currently practices family medicine with Carrier Sekani Family Services, located on the traditional territories of the Lheidli T’enneh (colonially known as Prince George), and also provides care through the First Nations Health Authority's Virtual Doctor of the Day program.

Dr. Sheona Mitchell-Foster is a settler obstetrician-gynecologist also based on unceded Lheidli T’enneh territory. In addition to providing high risk obstetrical care and full spectrum surgical gynecology, she teaches with the Northern Medical Program and has research interests in low-barrier options of cervical cancer screening for Indigenous women in the north.

Drs Alec and Mitchell-Foster share their experiences and learnings, and discuss how healthcare providers can strive to deliver culturally safe care, to uphold Indigenous people’s rights to self- determined health and wellness. They also share how they live their values, and find joy in sharing time and staying active with their families in Northern BC.

We’d like to note that Indigenous is a general term inclusive of First Nations, Métis, and Inuit. We acknowledge that inclusive terms have the potential to diminish diversity and the unique realities of different peoples. The use of Indigenous in this case is intended as an inclusive

commitment to improving health outcomes for each group.

Ultrasound departments everywhere have never been busier and patients with complaints involving all parts of the body visit the department every day. Ultrasound is the first line choice for visualization of the appendix when diagnosing possible appendicitis in children, young adults and pregnant women. When the appendix is not visualized on ultrasound, the patient may be scheduled for a CT which introduces additional radiation and may delay diagnosis and therefore delay treatment. At the University Hospital of Northern BC, finding the appendix was proving to be challenging and the department was visualizing the appendix at rates much lower than expected. Karina Hansen, the former ultrasound supervisor of the UHNBC ultrasound department and Carly Phinney, a Northern Health Quality Improvement Facilitator, teamed up with a local radiologist to tackle the problem, and were able to support the department to improve their appendix visualization and brought the rate up to 76.9%, representing a total increase in visualization of 42.4% from baseline. The change ideas they trialed were so successful, they have been adopted as routine practice by the sonographers and are being spread to other facilities throughout Northern BC.

Approximately 10% of the population (which translates to around 500,000 people in British Columbia) believes they have a penicillin allergy and are labelled as such in their patient records, but in reality, more that 90% of these patients do not have a true penicillin allergy. These false penicillin allergy labels can have serious consequences to both individual patients and the system; a false allergy label can lead to the use of an alternative antibiotic, which may have increased side effects, increased costs, and can lead to antibiotic resistance. Proactively ‘de-labelling’ patients that have an inaccurate penicillin allergy label can help avoid these risks. Dr. Tiffany Wong is a pediatric allergist based at BC Women’s and Children’s Hospital and is an advocate for choosing the best medications for patients, which involves proving or refuting true drug allergies. Dr. Wong and her team have developed a mobile de-labelling tool to support healthcare providers to do this work in their own settings with their patients. This involves a risk assessment and follow-up processes to accurately diagnose patients deemed as high-risk in a way that is safe, standardized, and evidence based. She has also been working with patient partners to co-design patient resources, so patients and caregivers can be empowered to understand penicillin allergies. These resources are available at https://www.dropthelabel.ca/. This work is also currently being adopted by local physicians and pharmacists at the University Hospital of Northern BC, with support from the Spreading Quality Improvement Initiative, so the benefits of penicillin allergy de-labelling, and associated improvements to patient care, will be realized in the North. Dr. Wong also shares how having a pet and participating in family based activities with her children and husband out in nature helps her to avoid burnout.

Links:

Drop the Label resources for providers, patients, and caregivers: https://www.dropthelabel.ca/

Assessment of multiple-opinion referrals and consults at the BC Children’s Hospital Allergy Clinic
Allergy, Asthma & Clinical Immunology Adam P. Sage and Elliot James and Megan Burke and Edmond S. Chan and Tiffany Wong DOI: 10.1186/s13223-023-00806-2
06/2023

In this episode, we are featuring the Physician Quality Improvement (PQI) program’s provincial alumni co-leads, Dr. Lawrence Yang and Dr. Hussein Kanji. Dr. Yang practices in a ‘family-family’ practice alongside his wife and brothers, providing cradle-to-grave care in Surrey, BC. Dr. Kanji is a critical care physician that works primarily in the ICU at Vancouver General Hospital and is passionate about developing the ECMO (extracorporeal membrane oxygenation) programming there. Both Drs Yang and Kanji came to the PQI program though a need to solve their own frustrations with the healthcare system. After graduating from their respective level 3 PQI cohorts (which is equivalent to the Virtual Action Learning, aka ‘VALS’, series offered by Northern Health PQI) and engaging with PQI for several years, they collectively took on the roles of provincial alumni co-leads. All physicians in BC that graduate from the PQI trainings join the provincial alumni network, which provides these physicians who are now experienced and knowledgeable in quality improvement methodologies and tools, to continue to apply their skills and passions to ongoing system improvement, while also engaging in a province-wide community.

As provincial alumni co-leads, Drs Yang and Kanji work together (Kanji describes himself as the ‘yin’ to Lawrence’s ‘Yang’) to support, embody, and connect with all quality improvement enthusiasts across the province, and facilitate ‘cross-pollination’ of ideas to drive positive change. They also share their love of all of the spectacular nature we are blessed to have in BC and share their strategies for preventing burn-out and maintaining mental health while working in such fast paced careers.

Dr. Shannon Douglas grew up in the Omineca area of Northern BC and has been dog sledding in the Fort St James area since her youth. She now practices medicine in the same region and is the Medical Director for the Lakes Omineca region and loves the diversity of patients she cares for everyday. This region includes Vanderhoof, Fraser Lake, Fort St. James, Burns Lake, Southside and Granisle. Chronic pain is a debilitating, complex condition that effects >60,000 people within the Northern Health region, and many patients use opioids to manage their pain. In 2016-2017 it became apparent that that opioid prescribing for chronic pain was contributing to the opioid overdose public health crisis. There was a need for improved processes for patients to access their medication in a way that was safe, timely, and evidence based. Dr. Douglas initiated an improvement project aimed at redefining the way chronic pain patients were supported in primary care. She worked together with the local interprofessional team to create a new pathway and screening process, that ensured prescription renewals became comprehensive care episodes. Changing the approach required self-reflection and challenging the status quo of 'the way it's always been done’. The project was successful, and patients really enjoyed the new approach, since getting medication can be really challenging for chronic pain patients. Ultimately the patients were able to manage their pain in a safe and supported way, and many were empowered to eventually transition away from opioids.

The Northern Medical Program (NMP) is an inspiring Northern success story based on community action. The NMP is a unique medical undergraduate program that educates future doctors with a focus on rural health. Dr. Paul Winwood is the current Regional Associate Dean of the program, a position he has had for over 10 years. Originally from the United Kingdom, Dr. Winwood settled in Prince George to practice gastroenterology, academic medicine, and provide leadership to the NMP. He loves the community here and especially enjoys spending time outdoors with his family, skiing in the winter and boating in the summer. In this episode Dr. Winwood shares the history of the NMP and describes the various ways the program ensures the quality of education, performance, and learning experiences of the students. We discuss how the profile of medical learners has changed to improve the diversity of physicians entering medical practice, and how the program has influenced physician retention in the North, especially in Indigenous communities.

In this episode, Qualitycast North is leaving the snowy North (yes we still have snow in March) and heading South to showcase some of the excellent Quality Improvement work being done by 2 physicians in the Fraser Valley area; Dr. Diala El-Zammar and Dr. Raj Johal. Dr. El-Zammar and her family came to Surrey, BC, Canada from Lebanon when she was 9. A self-described ‘nerd’, her love of sciences led her to medicine, and she now practices in the Emergency Department at Chilliwack General Hospital. Dr. Johal also grew up in Surrey and was influenced to pursue medicine by his parents who worked in healthcare and the sciences. He is currently a family physician in his hometown of Surrey and is the provincial PQI champion for publishing.

Dr. El-Zammar shares her very successful and innovative quality improvement work in implementing a virtual follow up process for emergency department patients. Integral to quality improvement is sharing the work and results through a variety of media including publishing. Also in today’s episode, Dr. Johal discussing the topic of QI publishing, including the why and how of publishing QI work, and what supports are available to PQI teams, and we’ll hear about Dr. El-Zammar’s experience publishing her QI work in the ‘BMJ Open Quality’ journal. They also share what they enjoy most about living and working in BC.

You can read Dr. El-Zammar and Dr. Johal published article here:

El-Zammar D, Johal R, Eng J, Schultz, T. Implementation of an emergency department virtual follow-up care process in a community-based hospital: a quality improvement initiative. BMJ Open Quality 2022;11:e001782. doi: 10.1136/bmjoq-2021-001782

Dr. Magda Du Plessis is passionate about maternal care, providing the best patient care possible, and quality improvement. She is part of the multidisciplinary team at the Chickadee Maternity Collaborative in Dawson Creek, BC, that includes other physicians, nurses, midwives, pharmacists, and administrative staff. Dr. Du Plessis led the team through a quality improvement project that aimed to have 100% of eligible pregnant patients in the South Peace registered with the Chickadee Maternity Collaborative, to ensure comprehensive, wrap-around care, while also seeking to decrease the rate of caesarean sections and patient safety events. With support from a physician quality improvement coach and a practice support coach, and the use quality improvement tools, the team met their goals; within the first year of operation 100% of eligible patients were registered within the collaborative, the caesarean section rate dropped from 33% to 25%, and there were zero patient safety reports. Dr. Du Plessis credits this success to teamwork, coaching, and the passion of the team. While there were challenges, patients ultimately appreciated the new, team-based, collaborative model of care that includes longer appointment times, and supportive discussions throughout the reproductive health experience. She also shares how her and her family enjoy all of the recreational activities the South Peace has to offer, from fishing, to skiing, to snowmobiling.

Growing up, Dr. Danette Dawkin didn’t initially see herself pursuing medicine, but after receiving a pamphlet for UBCs rural medicine program, she was inspired to apply, and is now a family physician that has provided services in many rural and Indigenous communities across the North. Implicit biases are unconscious assumptions that can affect how patients are treated based on characteristics such as race, gender, weight, drug-use, and marital status. Dr. Dawkin recently developed a reflective-practice based course to improve cultural safety in healthcare services in the Northeast community of Chetwynd, BC. She brought together an interdisciplinary, dynamic team to learn, discuss and reflect on the internal, implicit biases that we all carry, with the goal of providing care that is rooted in humility and curiosity. Dr. Dawkin shares her experiences with the uncomfortable and difficult work of confronting our own implicit biases, why this approach is so challenging, and how it can ultimately make care safer for everyone.

Have you ever wondered what the CEO of a large, complex, healthcare organization does, or how leadership and governance supports quality care? In this episode of Qualitycast North we further explore the relationship between quality and healthcare leadership through a conversation with the longest serving Health Authority CEO in recent provincial (BC) history, the current CEO of Northern Health, Cathy Ulrich. Cathy shares her journey through her early career in rural nursing, to rural operational leadership, to strategic leadership. Cathy also discusses her love of gardening, her appreciation for the people within our organization and the people we serve, and outlines her top 4 lessons for successful leadership.

Dr. Helene Smith is a Family Practitioner based in Quesnel BC, and also the Chair of the Northern Health Medical Advisory Committee, also referred to as NH-MAC. Originally from South Africa, she found her niche in rural family practice, and eventually became more involved in leadership roles.

Since late 2020, provincial healthcare has been making efforts to improve cultural safety for Indigenous patients and healthcare workers. In this episode, we explore the relationship between medical leadership, cultural safety and humility, and quality. Dr. Smith shares her vision for cultural safety and the commitment that medical leaders have made to a cultural safety action plan. She also provides an informative overview of the purpose and structure of the Northern Health Medical Advisory Committee, and how it influences physician quality in Northern Health.

Dr. Breanne Abbott is a primary care physician at the Stikine Health Centre, which is located on the traditional territory of the Tahltan Nation, in the community of Dease Lake. The Stikine Health Center is one of Northern Health’s most remote clinics and services an area the size of France, with the closest critical care facility nearly 600 kilometers away. Dr. Abbott first visited the area as a medical student and was amazed by the opportunities for recreation, the natural beauty, and the friendly community. After completing medical school and returning to Dease Lake to practice, she now shares the experiences of the area with her husband and son, who all love their time there.

Maintaining clinical skills and competencies is key for providing quality health care, especially in urgent, life-threatening situations in remote locations. When Dr. Abbott became interested in doing a Physician Quality Improvement (PQI) project, she saw an opportunity to focus on supporting the Stikine Health Centers small but mighty team to maintain their life support skills. The aim of her project was to improve the comfort and competence of health care professionals providing cardiac emergency care in the Stikine area by 50%. To meet this goal, she acquired a cardiopulmonary resuscitation (CPR) meter and facilitated the funding and logistics to have trainers travel to Dease Lake to provide on-site basic life support (BLS), advanced cardiac life support (ACLS) and pediatric life support (PALS) recertification training tailored for the local, remote context. Overall, her project was a resounding success! Not only was the project a great opportunity for team building, but the team was also able to see improvements in all measured areas of the project. Dr. Abbott has since put her PQI training to use on further projects, such as remote airway training, and improving availability of blood products. You can learn more about Dr. Abbotts project, and view her storyboard here:
BLS/ACLS/PALS Certification Improvement in Dease Lake | Northern Health PQI Projects (nhpqi.ca)

Qualitycast North is thrilled to kick off its second season by featuring Dr. Herman Johal, and his quality improvement work on creating an intubation checklist for the emergency department physicians at the University Hospital of Northern BC (UHNBC), located in Prince George, BC, Canada.

Dr. Johal is an emergency medicine physician practicing at the emergency department at UHNBC. He spent his childhood in Prince George, and after attending medical school, returned full circle to serve the community he grew up in. He credits the amazing healthcare team and collaborative environment of the UHNBC emergency department for creating an enjoyable work environment.

Medical intubation is the process of inserting a breathing tube into a patient's airway to assist breathing in cases of severe illness or trauma. Drawing from the INTUB study (Russotto et al. 2021) and concepts of the surgical safety checklist (Haynes et al. 2009), Dr. Johal saw an opportunity to improve team dynamics, communication, and patient safety during intubations. He developed and implemented a local, standardized intubation checklist and a point-of-care reference card for emergency physicians, which was very well received by the team; 100% of Nurses & MDs surveyed say they would promote the ongoing use of the checklist.

Additional information and storyboard: Development of an Airway Checklist for UHNBC Emergency Physicians | Northern Health PQI Projects (nhpqi.ca)

References:
Russotto V, Myatra SN, Laffey JG, et al. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA. 2021;325(12):1164–1172. doi:10.1001/jama.2021.1727

Haynes AB, Weiser TG, Berry WR, Lipsitz SR, Breizat AH, Dellinger EP, Herbosa T, Joseph S, Kibatala PL, Lapitan MC, Merry AF, Moorthy K, Reznick RK, Taylor B, Gawande AA; Safe Surgery Saves Lives Study Group. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med. 2009 Jan 29;360(5):491-9. doi: 10.1056/NEJMsa0810119. Epub 2009 Jan 14. PMID: 19144931.

Dr. Chui and Deanna reflect on the first season of Qualitycast North, discuss their favorite moments and most popular episodes, and provide some insights into some of the exciting quality improvement work that will be featured in season 2.

Magnetic resonance imaging (MRI) is a medical imaging technique used to create detailed images of organs and tissues inside the body. During an MRI scan, the patient must lie completely still in a confined space , which can be anxiety inducing, leading to fidgeting and movement. Any movement during the scan will result in lower quality images, which may require a repeat scan which is not only expensive, but is inconvenient for patients and contributes to longer wait times. Dr. Shyr Chui, a radiologist and the usual host of Qualitycast North, moves to the other side of the interview table to tell us about his work improving MRI (magnetic resonance imaging) scan quality and patient experience in the MRI department at the University Hospital of Northern BC (UHNBC). By engaging a team of medical radiology technologists, nurses, and clerical staff in a kaizen event to collaboratively develop improvement ideas, the project was successful in increasing the percentage of high quality scans and providing a better patient experience. Dr. Chui also shares his motivations for starting a podcast, the importance of the right care in the right place at the right time to ensuring quality healthcare, and discloses his dislike of maths. This is our final episode of season 1 – we will back with new episodes in fall 2022.

Originally from rural Saskatchewan, Dr. Kalah Blackstock now practices medicine and is raising her young family in Smithers BC, a place she describes as a fun place to live and a supportive community for raising kids, where she loves the ‘mild’ winters. Dr. Blackstock and her team at the Northern Roots Primary Care Clinic recently sought to improve care for diabetic patients and prevent downstream complications and empower self management by focusing on increasing physical exams and frequency of the hemoglobin A1C blood test (which measures average blood sugars over several months). Their goal was to ensure 75% of diabetic patients had a physical exam and 3 hemoglobin A1C blood tests annually, and the team worked towards this by creating a standardized diabetic lab requisition, by implementing reminder calls to patients, and by coming together to learn about and prioritize quality improvement as a team.

Dr. Jon Fine began his career as a physician in 1976 stationed in Germany with the British Royal Army Medical Corps. He came to Canada and started a family practice in Quesnel in 1981, also creating a geriatric assessment service in 1996, and has since continued to specialize in the care of elderly patients. Dr. Fine has led multiple quality improvement projects aimed at reducing emergency room visits and hospital admissions of elderly patients. He emphasizes that quality healthcare should reflect the values of the patient and their family, and should provide services to ensure that older people can enjoy their lives in comfort and dignity. He also reflects on the joys of living in Northern BC, such as skiing with his grandkids, fishing, and wildlife viewing from his own backyard. After over 40 years in medicine, Dr. Fine began his well deserved retirement on April 1, 2022.

Duane Jackson is of the Fireweed clan of the Gitanmaax people of Old Hazelton and has lived the majority of his life in Prince Rupert on the Northwest Coast of British Columbia. Duane has been a patient advocate with the Patient Voices Network for over seven years with engagements including cultural safety and humility, at-risk youth, and positive patient partnership. In this episode, Duane describes his advocacy work, the importance of collaboration and shows us his ability to bring people together. Duane shares how embracing humility is the key to engaging in positive change. His vision for quality care is a system that is culturally safe for everyone (on both sides of the gurney), where anyone can walk through the door knowing they will find safety; an environment free of risk, compromise, and vulnerability. He provides advice for both providers and patients interested in incorporating patient lived experience into healthcare improvement, reminding us the door is open – we just have to find the courage to jump in with both feet.

Dr. Denise McLeod has always had a passion for caring for others. She worked for 12 years as a nurse before pursuing her dream career as a family physician. In her current practice she cares for patients across life’s spectrum, from newborns to palliative care. To better support her patients with chronic obstructive pulmonary disease (COPD), which is the 4^th leading cause of death in Canada, Dr. McLeod started group medical visits, with the goal of improving self management to avoid emergency room visits. These innovations not only improved things for her patients, but also inspired other physicians to adopt COPD group medical visits in their communities.

Prince George physician Dr. Matthew Wahab spent several years as a software developer before eventually deciding to pursue a career in medicine. He now loves going to work everyday in the Emergency Department at UHNBC and greatly appreciates the good personal and professional quality of life practicing in the North provides. In this episode Dr. Wahab shares how quality improvement helped him tackle the annoying problem of a lack of proper visual acuity checks being done on patients with eye complaints. Throughout his project, he and his team were able to improve the percent of completed visual acuity checks from 57% to 84%. He also discusses the importance of building a culture that is tolerant of change, and how consistent communication with all stakeholders is key for quality improvement initiatives to be successful.

A passion for hockey and sports eventually led Dr. Joe Costa to a career in orthopaedic surgery. Orthopaedic surgeries always require diagnostic images, such as x-rays, but due to variation in ordering pathways, up to 30% of x-rays ordered are not what the surgeon is looking for. This leads to repeated x-rays which are expensive for the healthcare system, and frustrating for patients. In this episode Dr. Costa discusses how he and his team aimed to improve the proportion of appropriate, complete, and necessary diagnostic images for MSK (musculoskeletal) problems from 70 – 90%. He also shares his ‘earth-shattering’ realization that Quality Improvement science and methodology are instrumental for creating successful change, and reflects on the privilege of working with Northern patients, and how practicing in Northern BC allowed him to achieve the dream of a backyard hockey rink.

Additional Links:

Dr. Joe Costa leads efforts to streamline referral process to musculoskeletal consultation and care

In this episode we interview Dr. Anurag Singh, nephrologist and Medical Lead for the Northern Health Kidney Care program. Dr. Singh discusses the challenges he and his team face providing a regional kidney-care service across the massive geographical area of Northern BC, and how implementing a new telemedicine service improved care for patients in rural communities. In addition to improving access to care in rural communities, the tele-kidney care project achieved success in increasing the uptake of home dialysis to 22% (making it the highest in the province), and resulted in patients being referred for services earlier in their disease progression. Access to tele-kidney care also resulted in savings of an average of $375 in travel expenses and eliminated 839 km of travel per patient ($300,000 and 863,883km total). Dr. Singh also reflects on the professional rewards of practicing medicine in Northern BC, and the personal satisfaction of living in a community so close to nature.

Additional Links:

• BC Patient Safety Quality Council awards: Tele-Kidney care in Northern BC
• NH Stories Tele-kidney care
• Dr. Anurag Singh: Physician Highlight - How do we address the challenge of providing fair access to specialized services to patients in the remote communities of Northern BC?
  

In this episode Dr. Shyr Chui talks with Prince George Family Practitioner Dr. Omowumi Iyaoromi about the unrecognized problem of weight bias in healthcare, what it is, how it affects patients and how to reduce its impact on healthcare quality. Dr. Iyaoromi shares the success she had with improving weight bias amongst a team of healthcare professionals as measured by the BOAP (beliefs about obese people) scale, her experiences using the EOSS (Edmonton Obesity Staging System) tool in clinical practice, and describes what she enjoys most about living and practicing in Northern BC.