We look forward to a lively discussion at Vancouver’s All-Staff Forum on Monday, April 7 (3 to 4 pm). More than 150 people have already registered, so we recommend registering with CCRS early.

In the meantime, we’re happy to answer more of your questions. Please excuse the length of some answers, but in response to your feedback, we’re trying to provide more specifics in our responses.

Today’s answered questions

Q. Can you speak specifically about how you are evaluating the effects of the redesigns? Not just cost savings but also client outcomes.

A. Yes, we’re happy to provide examples of evaluation — we have no shortage of them! At a system level, both the Ministry of Health and VCH set targets we all strive to achieve. These targets and our outcomes are published regularly for the public at vch.ca.

We also evaluate Vancouver projects and redesigns in multiple ways, and we don’t embark on change without establishing targets for patient outcomes, quality care and efficiencies. Along the way, we monitor results — in some cases on a weekly basis — and, when necessary, we adjust course to ensure we’re delivering the best care to the right people at the right time, effectively and efficiently.

There are just so many examples we could discuss, so for the sake of brevity we’ll focus on three here: one acute-community collaboration, one community program and one acute redesign:

• Acute-Community– In January 2014, Community’s Quick Response Team and the VGH ED began a new and ground-breaking collaboration. Together, they’re providing a wraparound approach to care for frail seniors, especially those with chronic conditions, to help them avoid unnecessary admissions to hospital. Our aim is to help these patients return and stay home safely, with the right supports. To evaluate the impact of this initiative, we’re tracking a number of measures, including the ED admission rate, patient readmissions/ED revisits and client and family satisfaction. It’s still early days, but the early indicators are positive. On average, every day two additional frail elders are transitioning home rather than being admitted to the hospital, where they’re at less risk for falls, infections, etc. Over the course of a year, this average could mean 730 more clients remaining in the comfort of their own homes. We’ll continue to monitor all measures to track outcomes.

• Community – The first Assertive Community Treatment (Act) team accepted clients in January 2012. ACT teams provide 24/7 health care and life-skills support, primarily for severely addicted and mentally ill clients in Vancouver’s Downtown Eastside. ACT teams help keep clients healthy, out of hospital and away from the criminal justice system — all of which is measured and reported out regularly to the VCH Senior Executive Team and Board. Based on the literature, we expected to see hospital visits decline readily after the first team began working. Instead, we saw visits increase in the short term because many clients suffered from COPD and other chronic conditions and they had not had regular contact with the health care system. Clients required acute treatment for stabilization, and we adjusted our services accordingly. Today, results exceed our original targets. Since January 2012, clients’ length of stay in acute care has decreased by 80%, and ED visits have decreased 70%. Also, a recent sampling of ACT clients shows that police contacts are down by 50%, compared to our target of 20%. Today, five ACT teams work in Vancouver and are in the process of expanding their total caseload to more than 400 people.

• Acute – On February 11, 2014, the VGH Clinical Teaching Unit (CTU) began operating under a new model to improve the quality of care, access and education. Previously, physicians’ patients were scattered throughout the hospital, requiring a great deal of travel between hospital pavilions and floors — time that should be spent on patient care. Today, most CTU teams have a defined home base, an assigned medicine unit where medical students, interns, Residents and Attending Physicians provide care for nearly all the patients on that unit. Another team is dedicated to the Emergency Department. Before embarking on the redesign, a baseline of evaluation measures was established to track the impact of changes from both quality and efficiency perspectives. Less than two months in, the redesign is showing positive impacts already. Physicians are spending more time with their patients and bedside staff to improve care and discharge planning. Continuity of care is meeting target: the physician who initially sees the patient in the ED continues as the patient’s Attending Physician 75% of the time. Congestion is easing in the ED, and inpatient length of stay is trending down, while safe and supported discharges are increasing. For example, the Acute Medicine unit discharged 24 more patients than predicted within the first month of implementation. Ongoing evaluations of patient and family satisfaction will round out the picture, and we’re working with an evaluation team from the residency training programme to evaluate the effectiveness of our teaching efforts.

The other measure of success we haven’t touched on yet is staff feedback on program changes. We rely on staff’s first-hand experience to inform our decisions and adjust as needed. At VGH, for example, Dr. Iain Mackie, interim medical director of the CTU, will be consulting with allied health staff for their feedback and input for continued enhancement.

We hope this provides you an idea of the many ways we evaluate. If you’re looking for information on a specific redesign or project, please let us know.

Q.  One of the gaps that I have noticed in VCH is the inconsistency of practices across VCH and in many areas.  For example, in my role, I interact with VCH sites regionally and I have found that practice in using the assessment tool that I teach to be different in Richmond, in Vancouver, in Coastal.  Every site has its own culture and practice, even though all received the same initial training.  There are also factors such as the slow process of change in the organization, and a lot of times, it seems like there are mental barriers to innovation and change.  This poses many challenges, inconsistencies, duplication of work and creates frustration; I’m sure that it is not just our team that experiences it.  It feels like the work, time and effort that is put in is undone when the clinician receives the education and then returns to their own area to be ‘taught how things work in the real world’.  I think of a comment made by David Ostrow in a regional forum that he also has seen the inconsistency in medicine and other areas as well.  There is a lot of overlap right now and it feels like when regional direction is sent out, there are other stakeholders or parties involved that would override or dismiss it.

My suggestion is for consideration to be made within the organization chart/structure for a regional role(s) in home care, acute care, residential where that person has the authority and power to standardize practice and policy, based on best practice, all the while supporting the specialized teams such as the one I am a part of, in our leadership and expertise.

A. Thank you for your suggestion. You’re right — change can be difficult, and especially so when people approach change from different vantage points. And, yet, we all share the same goal: deliver the best care as effectively and efficiently as we can. Fortunately, our Clinical & Systems Transformation (CST) project will help us achieve that goal.

CST is about much more than a system or even an electronic health record. Through CST, we’ll create standardized, evidence-informed clinical practices across VCH, PHC and PHSA. We’ll also create an integrated clinical information system (CIS) capable of letting users generate immediate, more complete and accurate health records.

The CST project is currently in Phase Two (Design, Build and Integrate). Starting April 7, 2014, design teams, which include a broad range of professionals and subject matter experts (SMEs) from across VCH, PHSA and PHC, will begin the work to design our new clinical practices and shared clinical information system. This work will be reflected in new policies and procedures in acute, residential and ambulatory care. In short: more of us will be doing the same things in the same way and you should see less variance in practice once CST is launched.

More importantly, CST will enhance the patient experience. Patients will benefit from more seamless, quality care throughout VCH and across our health organizations, and they’ll have faster access to care and results. To learn more about the CST project, visit the new CST website: CSTproject.ca

Q.  Nurses advocate every day for their clients but I personally feel we step back when it comes to us. This is me stepping up as a nurse for a nurse. Flu vaccines are available to all especially recommend for immune compromised individuals. If someone chooses not to get vaccinated they hold the risk of catching the flu. Although the flu vaccine is to protect people from severe forms of the flu everyone has the right to choose. If people choose to take the chance then why force nurses to get the flu vaccine. I personally had seen a client today who had a hard time hearing me and requested I take off my mask as she did not care if I had the flu shot or not. Washing hands have always been the best way to protect one’s self.

So my question is why is it that everyone in BC gets the choice to get a flu vaccine except the nurses? Yes it is not mandatory but the mask implementation makes nurses give up. If patients are okay with nurses who have not had flu shot then why enforce such a policy? Make hand washing mandatory, make nurses who are sick stay home and revisit this policy please.

A.  Thank you for asking these important questions. First, we’d like to clarify that B.C.’s influenza control policy applies not just to nurses but to all medical staff, physicians, students, volunteers, contractors and vendors working in B.C. health care facilities. Under the policy, no one is forced to get a flu shot; health care workers have the option of getting a flu shot or wearing a mask during flu season. For the 2012/13 flu season, the policy was expanded to include all visitors to health care facilities.

Flu vaccination is recommended for everyone in B.C., and is provided free to all who may be at high risk of complications — such as those with compromised immune systems, pregnant women, young children and the elderly — but also to those in close contact with these groups and who could expose them to influenza. This includes health care workers, but also family members and household contacts, daycare workers and others.  Because people infected with influenza are infectious to others before they develop symptoms, it’s extremely important that those in contact with vulnerable people are vaccinated. And this is especially important when you consider that the frail elderly don’t respond to the flu vaccine in the same way as healthy adults — they can still be infected after vaccination.

Regarding hand washing, it’s very important in preventing many infections, and improving our hand hygiene remains a priority, but hand washing isn’t the best protection against influenza. That’s because influenza can be transmitted from infected health care workers to patients by coughing, speaking to or even breathing near them. While we know vaccination is the best protection, masks have been shown to also provide protection and are considered an acceptable alternative to vaccination — as long as they’re worn consistently. So, whether we’re wearing a mask for patient safety reasons, to prevent transmission of the flu, or while working in the OR as part of infection control guidelines, we shouldn’t remove our masks on patient requests. Instead, we should explain why wearing a mask is necessary for their protection.

B.C.’s provincial health officer officially declared March 31, 2014 as the last day of the 2013-14 influenza season. This means that unvaccinated staff, physicians, volunteers and visitors are no longer required to wear masks at health care facilities.

We hope this answers your questions, and we encourage you to read the latest news on this season’s flu season and our record-breaking vaccination rate here.