Winnipeg Health Region Wave, January / February 2014
Innovation. It's a word that gets tossed around a lot in industry, whenever people discuss the importance of improving products, procedures and services.
But innovation also drives quality improvement in health care, according to Dan Skwarchuk, Executive Director of Health Services Integration and Innovation with the Winnipeg Health Region.
"Our goal is to enhance the quality of services, access to existing services, efficiency in the provision of programs and services, and deliver things in a new way," says Skwarchuk.
Over the next year, staff of the Winnipeg Health Region will push forward with dozens of innovations designed to enhance the delivery of care, ranging from initiatives to reduce wait time for surgeries to helping people take more control over their own health.
In virtually every case, innovation will be driven by front-line health-care workers, those who have direct contact with patients, clients, and residents, says Skwarchuk.
"We have an amazing workforce of very bright people with lots of great ideas. They know what needs to change," he says. "We're listening to what they have to say."
The Region uses Accreditation Canada's eight dimensions of quality when evaluating whether to implement change, including whether the new idea will increase access to services, whether it puts patients and families first, and whether it's doing the right thing while making the most of current resources.
In pursuing innovation, Skwarchuk notes, "We have to take small, calculated risks, in order to change. Sometimes, things go wrong. But just because an idea fails, doesn't mean it's not a good learning experience. Afterward, tracking each innovation and evaluating its performance shows whether new ideas work and could be spread across the Region."
It's not just Region staff working for change. Innovation also involves working with academic institutions, the provincial government, other health-care organizations, and the vendor community that supplies the Region with materials and services.
To highlight the work taking place within the Region, staff have selected seven initiatives that are expected to enhance care for thousands of patients in 2014. Some of the initiatives featured on the following pages are already underway and are being evaluated. Others will launch this month or in the near future.
"Innovation, by its very nature, can be incremental or very radical," says Skwarchuk. "It can relate to small, marginal changes in how we provide programs and services. Or it can completely change the way in which we do things."
Kidney disease screening
As many as 3,000 residents living in 11 First Nations communities will be screened for kidney disease over the next two years in a bid to improve kidney health among Manitoba's Aboriginal people.
The initiative, known as First Nations Community Based Screening to Improve Kidney Health and Prevent Dialysis (FINISHED), was conceived as a joint effort between the Diabetes Integration Project (DIP), a mobile screening program headed by Caroline Chartrand that operates in 19 First Nations communities, and some Manitoba Renal Program nephrologists, including Drs. Paul Komenda and Claudio Rigatto.
Under the program, mobile teams consisting of registered nurses and health-care aides visit each community with a view to screening all residents between the ages of 10 and 80.
Screening of residents living in Ebb and Flow First Nation, located about 83 kilometres east of Dauphin, will begin this month. Residents living in the Island Lake and West Region Tribal Councils are also participating in the program.
Komenda and Dr. Barry Lavallee, two of the lead physicians for FINISHED, say the program's goal is to reduce the number of First Nations people who end up on dialysis due to kidney disease.
First Nations people in Manitoba suffer from the highest rates of kidney failure in the country, with a 20 per cent risk of death in the first year, and 50 per cent within five years. Patients with kidney disease often end up on dialysis - which can cost the health-care system as much as $550,000 over the life of a patient. Kidney transplant waiting lists are long, and many patients are not candidates for this treatment. First Nations patients requiring dialysis are often uprooted from their communities, forced to quit work or school, and face multiple hospitalizations as a result of dialysis.
The screening program is unprecedented and has the potential to have a tremendous impact on the health of people living in First Nations communities, as well as on the province's health-care budget. "We've never done a mass screening of this many people before," says Komenda.
Under the program, nurses gather data from participants, including age, sex, weight and blood pressure. Blood and urine are analyzed using state-of-the-art point of care technology. Data are entered into an iPad application that uses an algorithm developed by renal program nephrologist Dr. Navdeep Tangri to predict a person's risk of developing kidney failure in the next two to five years.
"This tells us who is at low-, medium- or high-risk," says Komenda. The mobile team alerts each person's primary-care provider about the individual's risk level. Those who are at high-risk are referred to the Manitoba Renal Program high-risk inter-professional clinic team for immediate treatment at Seven Oaks Hospital.
The FINISHED program combines leading-edge medical technology with traditional knowledge and indigenous health services, says Lavallee, Director of Student Support and Curriculum Development with the University of Manitoba's Section of First Nation, Métis and Inuit Health in the Faculty of Medicine. "Relationship development is paramount to success for this program."
To develop those relationships, the Manitoba First Nations Diabetes committee was consulted on protocols, including sharing the collected data with the communities. Aboriginal Diabetes Initiative workers in each community were also involved, says Lavallee, noting they have been key to the project's success.
"Our communities struggle with many barriers, mostly remnants of and continuing colonization. Challenges in living with high levels of poverty impact one's ability to eat healthy. First Nations communities want their members to live well and be healthy. This project suits those community values."
The FINISHED program is funded by Health Canada's Health Services Integration fund. Eleven First Nations communities will be screened by 2015 under the program, which began in 2012.
Improving patient flow
About 1,000 patients undergo surgery at Misericordia Health Centre's Buhler Eye Care Centre every month for issues ranging from cataracts to retinal problems. That's up from about 750 eye surgeries a month just three years ago.
As one might expect, the jump in traffic posed serious challenges for staff. They had to figure out how to handle the increased flow of patients without adding staff or resources. Their solution: reorganize the department to improve work flow and enhance patient comfort.
One of the first changes involved redoing the layout of the fourth floor eye surgery area, says Barbara Ginter-Boyce, Patient Care Manager for the Pre-op Assessment, Day Surgery, Recovery and In-Patient Eye Unit at Misericordia.
Previously, surgeons had pre- and post-operative assigned spaces for their own patients, on either side of the hallway. It was noisy and confusing, says Ginter-Boyce, with patients coming and going all day, and nurses prepping patients lying on stretchers, waiting their turn for surgery.
Today, the floor has been divided into an A side and a B side. The B side stands for "before surgery." It is a long room where pre-operative patients sit in recliner chairs instead of on stretchers. They can talk to each other or to their family members, says Ginter-Boyce. Patients also wear their own clothing, another way of making them more comfortable, rather than the previous method of having them change into hospital gowns.
The A side of the floor is the "after surgery" room. Here, patients are monitored as they come out of sedation, are given a small snack and drink after their pre-surgical fast, and given instructions on how to care for their eyes once they return home.
"We do approximately 60 to 70 surgeries a day," says Ginter-Boyce. "There are 23 surgeons on staff, which means we have four cataract surgical suites going, along with one retinal suite and one pediatric dental surgery room. Having the patients start on the B side, move into surgery, and then into the A side really helped with flow."
In addition to reorganizing the area, the department has also implemented an electronic medical record system and is considering changing the way pre-op assessment nurses work with patients slated for eye surgery, says Gillian Toth, Director of Acute Care Programs at Misericordia.
Currently, nurses can make more than 1,000 calls a month to patients, providing them with instructions on how to prepare for surgery. Instead, Toth says the department is looking at using a recorded phone message to provide instructions. "People can listen to (the messages) as many times as they want. They can leave a message for us if they have questions, and the nurses will call them back," she says.
Another goal is to record post-operative instructions - such as how to use eye medications or when to remove the shield over the eye - and show them on a television in the waiting area. Each patient will still receive individual instruction after surgery, but the majority of the instructions will already have been done, says Toth.
Kim Storer is learning to take control of her health.
The Winnipeg woman is one of 15 people participating in a group program at Lord Nelson School that is based on the Japanese health-management system known as Hans Kai (which translates as "small group").
Launched last fall by the Winnipeg Health Region and NorWest Co-op Community Health Centre, the Hans Kai group meets regularly at Lord Nelson School to monitor their health and discuss wellness-related issues.
Most of the participants want to maintain a healthy lifestyle, and a few are dealing with diabetes or high blood pressure. During a typical session, they check their blood pressure and blood sugar levels, listen to a talk on a health issue such as diabetes, eat a healthy snack and exercise. And they do all of this without assistance from a doctor or nurse.
Storer says the weekly sessions are empowering. "We log our vital signs and track our activities," she says. "After six months, we'll go through an interview to find out if what we're doing has made a difference in our health."
Evan Zarecki, one of two community development co-ordinators with the Region who oversee the Hans Kai program in northwest Winnipeg, says the group dynamic creates an opportunity for people to help themselves - and each other.
"We know that social, physical and mental health all improve with a connection to the community," says Zarecki. "People are often living in isolation and don't have anyone to talk to about how they're doing. By getting together and talking, they not only learn how to maintain a healthy lifestyle, but how to seek help from health-care professionals when they need it."
So far, NorWest and the Region have launched 14 Hans Kai groups in the Inkster and Seven Oaks communities. The groups meet regularly in seniors' centres and residences, community centres, churches, schools and people's homes.
"Participants range in age from 21 to 100, with about 46 per cent of them having some sort of chronic health problem," says Michelle Kirkbride, also a community development co-ordinator with the Region. "Some have hypertension, arthritis, mental health issues. I'd say that 85 per cent of the participants are women."
Anyone who wants to join a Hans Kai group, or start one of their own, must first attend an eight-week health course, taught by Winnipeg Health Region staff, that provides them with basic information about the goals for their groups.
Upon completing the course, participants start holding their own group sessions, usually weekly or monthly. The groups are supplied with a toolkit containing equipment and resources, such as a blood pressure monitor, glucometer and tape measure, and can call upon Winnipeg Health Region staff such as dietitians, nurses, pharmacists and kinesiologists as speakers.
Manitoba and Quebec were the first two Canadian provinces to adopt the Hans Kai method from Japan, says Kirkbride. The Winnipeg program has since trained people in Nova Scotia, British Columbia and Saskatchewan in how to establish such groups. NorWest and the Region are looking to adapt the Hans Kai concept for high school kids in 2014, says Zarecki.
"These groups will focus on youth, ages 15 and older, getting them talking about alcohol and drug use, relationships and other aspects of a healthy lifestyle that teens are interested in," he says. "We're hoping to instill healthy habits early, by getting them to think about going to see health-care professionals regularly, and learning how to empower themselves."
Researchers know that exercise can be used to manage diabetes. However, for people with the condition, it's not always clear what sorts of exercises they should do, or how often they should do them.
A program created by the Wellness Institute at Seven Oaks Hospital, through a partnership with Youville Centre and the YMCA-YWCA of Winnipeg, is providing answers.
Launched last fall, the Community Fitness for Diabetes Program is designed to help people manage their diabetes better through exercise. The program provides medical fitness expertise to support safe and effective exercise programming that participants can do on their own, at home or at the gym.
According to Manitoba Health, approximately 111,000 Manitobans will be living with diabetes by 2016, representing a projected 8.5 per cent of the population. Most of these people will develop Type 2 diabetes, which occurs when the body does not produce enough insulin or respond effectively to the insulin it does produce. This causes glucose levels in the blood to increase, and can contribute to a variety of health problems, including kidney disease, heart disease and blindness, to name a few.
People with Type 2 diabetes must monitor their blood sugar levels and may need to take insulin to control their condition. But it can also be managed by adopting a healthy lifestyle. This is where the Community Fitness for Diabetes Program comes into play.
"There's a fair amount of information out there on exercise, but none targeted to people with diabetes," says Dr. Kevin Saunders, a medical advisor with the Wellness Institute at Seven Oaks Hospital. "We've developed a targeted, safe program for people who are middle-aged or older, many of whom haven't exercised before."
The eight-week program is funded in part by Winnipeg Foundation and pharmaceutical companies Boehringer Ingelheim and Eli Lilly. It is available at the West Portage YM-YWCA, Youville Centre in St. Vital, and the Wellness Institute at Seven Oaks Hospital.
Program participants are assessed for any risks they might encounter when exercising, including a review of their medical history and medications, to ascertain whether they can safely take part in the program, which is led by certified exercise physiologists and diabetes educators. "Many people are sedentary, overweight and have more than one medical condition on top of diabetes," says Saunders. "The goal here is to teach the basics of exercise in eight weeks, and have people continue to do so at home, at a gym or at the Wellness Institute, hopefully for life."
In doing so, the developers of the program believe they can help people stave off some of the more serious effects of diabetes and enhance their quality of life. As Saunders explains, diabetes often leads to kidney disease, which can lead to dialysis, and eventually the need for a kidney transplant. Diabetes is also a leading cause of more wide-spread vascular disease, which leads to heart attack, stroke or blockages to the peripheral vascular system involving the legs, which can lead to amputation.
"We would like to catch people upstream of renal failure. Just by exercising, we know people can decrease the number of drugs they have to take per month," he says.
In addition to helping individuals improve their health, the program can also help control health-care costs, says Casie Nishi, Executive Director of the Wellness Institute.
A timely blood transfusion can save a life. So it stands to reason that speed is of the essence when acquiring the blood products used in massive transfusions performed during emergency surgery.
It was with this mind that the Massive Transfusion Protocol team was established at Health Sciences Centre Winnipeg last year. Led by hematologist Dr. Ryan Zarychanski and managed by process engineer Laurie Gosselin, the team was created after an internal review discovered that patients in need of massive transfusions didn't always receive them in a timely fashion.
The group, which consisted of more than 30 people, including staff from HSC, the Winnipeg Health Region, George and Fay Yee Centre for Healthcare Innovation, Canadian Blood Services and Diagnostic Services Manitoba, had one objective: speed up the process for delivering blood to patients in need.
It was not a simple task. At a busy hospital like HSC, there may be dozens of requests for blood every day from any number of departments, including emergency and intensive care.
That can make it hard to push through a priority call for a patient who needs a massive transfusion right away. Ordering the blood is just one piece in a complex system.
Verifying a patient's blood type, transporting samples and blood components, analyzing specimens, and even the process of transfusing blood components are other critical tasks. If any part of this process suffers delay, potentially life-saving blood is delayed.
The team discovered that in some cases a request for certain blood components could take up to several hours to process. "That is simply unexpectedly long," says Zarychanski.
In addition, the team found that the ratio of blood cells to plasma and to platelets was also far less than ideal in a significant proportion of patients. This ratio is important because, in the right ratio, blood components will support the patient and reduce bleeding, but in the wrong ratio, bleeding might increase and be harder to stop.
The team came up with a plan to hasten blood delivery and ensure a safe ratio of blood cells to other essential blood components. Under the proposed protocol, when a patient needs a massive transfusion, the attending physician activates a "transfusion 25" code. "This triggers a paging process that alerts the blood bank and many others that a massive transfusion protocol request is coming through the system," says Gosselin.
Diagnostic Services Manitoba accelerated result reporting by employing a faster method to centrifuge blood samples. The old process took 15 minutes, but the faster method can centrifuge a blood sample in four minutes.
In addition, the new protocol calls for blood to be delivered in "transfusion packs," which will continue to be sent as long as necessary.
"This represents a remarkably innovative aspect to the new protocol, which will help ensure an adequate volume and ratio of blood components are available and transfused," says Zarychanski.
The new protocol is being tested and is expected to go live in designated care areas at HSC this spring. Other hospitals are interested in adapting the model for their own use, says Zarychanski.
At times of acute illness, mental health patients may behave violently. This can result in injuries to health-care staff and fellow patients. Seclusion of an aggressive patient in a locked, quiet room is one of the ways to manage this behaviour.
But frontline staff at Health Sciences Centre Winnipeg's Mental Health Program felt there was a need for change, as seclusion goes against their philosophy of lessening restrictive care.
The catalyst for this change occurred when a nurse on the PY3S - Psychiatric Intensive Care Unit was injured during the seclusion of an aggressive patient. This nurse proposed a new approach based on an international training program - the Six Core Strategies for Seclusion Reduction - which promotes minimizing safety risks by forming more collaborative relationships between staff, patients and their families.
In 2011, trainers taught PY3S staff how to use the least restrictive treatments by encouraging patient participation in their own care planning, says Debbie Frechette, Director of Patient Services, Mental Health Program.
Staff members now work on a safety plan with each patient upon admission, identifying what situations trigger distress in the patient. They plan calming strategies that may be helpful in managing such situations. If the patient behaves aggressively, the safety plan is used. This reduces the risk of conflict and promotes a feeling of empowerment for the patient.
"By seeking input from the patients about their care, it caused a cultural shift that set up co-operation rather than confrontation," says Frechette. "We learned that seclusion doesn't always provide a safe, quiet atmosphere for people to calm down in; rather that it caused them to be alone with their thoughts, which can cause them to feel more fearful and unsettled at times."
The drop in the number of seclusions has been dramatic. There were 227 seclusions in 2010/11. That dropped to 100 seclusions in 2011/12 and further to 59 seclusions in 2012/13. "We anticipated a gradual decline in the use of seclusion, but to have this diminish by 56 per cent in the first year was wonderful," says Frechette, adding that the number dropped an additional 40 per cent in the second year.
Patients who did end up in seclusion spent significantly less time there. Total seclusion duration prior to the change was 2,395 hours in 2010/11, compared to 401 hours in 2012/13. This represents an 83 per cent reduction in the total duration of seclusion.
Prior to the change, almost all Workers Compensation Board injury claims by staff resulted from injuries incurred during the secluding and restraining of patients. Two years after the program changed, there was a 98 per cent decrease in the number of work days lost due to abuse injuries to staff.
Given the success of the change at PY3S, plans are underway to expand the seclusion reduction program to all mental health units at HSC, as well as to mental health units at other Winnipeg hospitals.
Connecting the dots
As Manitoba's population continues to age, the province's chronic disease rates continue to rise. And that means more effort must be put into building a health-care system that is patient/client-driven and can meet the growing demand for services in a way that is accessible and efficient.
Enter the Winnipeg Health Region's Chronic Disease Collaborative.
This four-person team works with sites and services to identify opportunities within the system for programs to come together to better serve members of the public.
"The collaborative was set up to work across the system to look for opportunities to connect and link people," explains Michelle Meade, Manager of the collaborative.
Within the health-care system, there are many people carrying out different tasks, from chronic disease management and acute care to education and prevention. But there are times when programs may overlap or unintentionally leave gaps in the network of care.
The collaborative brings together various groups inside the health-care system and within the community, to find ways to enhance and improve services and self-management opportunities.
Support for people with diabetes offers one example of how this approach works.
There are many players, from doctors, nurses and dietitians to hospital-based services and community programs, offering support for people with diabetes. The collaborative has led discussions with various groups to learn how they are providing services and identify opportunities for improvement.
"Some of the agencies said, 'You know, we are challenged by some of the really complex care needs.' Now we're working with Health Sciences Centre's Diabetes Education Program and Youville Centre, making sure that people with diabetes have access to the right care at the right place."
It's a whole system shift, says Meade, who also points out the importance of working with family physicians and other primary-care providers.
Another example of the collaborative at work involves the co-ordination of support for people with osteoporosis, a chronic disease that leads to weak bones and possible "fragility fractures." Unfortunately, people who experience fragility fractures (a bone break due to falling from a standing height or less) will often go undiagnosed for osteoporosis. The lack of a diagnosis means they may not be receiving the treatment and educational support that could help them avoid future fragility fractures.
"Only 20 per cent of people with these fragility fractures are identified for follow-up investigation or intervention," says Meade. "It is a population where we could be doing more to support patients and families." In order to help determine the nature and scope of that support, the collaborative, working with Manitoba Health, established a working group consisting of health-care providers involved in the treatment and support of people with osteoporosis, including those working in the hospital and in the community.
The group is just finalizing Manitoba guidelines that will be used to direct diagnosis and treatment of osteoporosis, as well as identify some opportunities to improve the patient experience.
Meade says the collaborative is also supporting important work in preventing chronic disease. They are linking programs for patients and training for health-care professionals so that Winnipeggers have multiple sources of self-management supports to make healthy changes and prevent problems before they start.
Susie Strachan is a communications advisor with the Winnipeg Health Region.