Regional Quality Improvement

Transcription

1 Specialist Services Committee and Interior Health Regional Quality Improvement January 12, 2017 Contact: Dr. Ron Collins - Executive Medical Director, Quality and Patient Safety ron.collins@interiorhealth.ca / x4008 Aman Hundal - Specialist Services Committee, Liaison ahundal@doctorsofbc.ca /

2 Table of Contents 1.0 Executive Summary SSC Regional QI Initiative Engagement with Interior Health Working Group Discussion Overview Summary Alignment / Structure Interior Health Reorganization Current Interior Health Quality Portfolio Goals / Objectives Proposed Model Physician QI Training Physician QI Participation Physician Engagement Opportunities/Examples Technical QI Team Budget Timeline Governance and Reporting Appendices Appendix A Letter of Intent Appendix B Five Key Strategies Appendix C IH Quality Structure Appendix D Physician Lead Quality Project Template Appendix E Job Descriptions Page 2 of 33

3 1.0 Executive Summary Interior Health (IH) provides health services to over 725,000 people across a large geographic area covering almost 215,000 square kilometres, the geography of which includes large cities and a multitude of rural and remote communities. Population health needs across the continuum of care drive the mix of services and enabling supports IH provides. This continuum includes staying healthy, getting better, living with illness, and coping with end of life. Service delivery is coordinated through a regional network of care that includes hospitals, community health centers, residential and assisted living facilities, housing supports for people with mental health and substance use issues, primary health clinics, homes, schools, and other community settings. Approximately 19,000 staff and 1,450 physicians work within IH to provide high quality health services. Majority of these physicians are fee for service and work very hard to provide timely access to care. Through feedback with physicians over the last year, it is clear they are very interested in physician led quality improvement activity. This proposal is grounded by the vision of physician as active partners in improving the quality of care. The proposal is requesting from the Specialists Services Committee (SSC) up to $1.22m annually to March 31, 2019 to establish sessional payment, QI training and technical support to enhance capacity for physicians to develop skills and knowledge to lead and participate in quality improvement efforts, and to promote an organizational culture in which physicians feel engaged and supported. In short, this proposal seeks to: Build capacity amongst physicians in quality improvement; Support physicians to undertake self-identified quality improvement projects in partnership with patients and families; Enable physicians to participate in the IH s quality improvement structures; and Develop a culture of engagement, support and continuous quality improvement amongst physicians. This proposal outlines our co-created vision to build quality improvement resources that support a team approach to continuous quality improvement. The proposal was created collaboratively with the SSC and with direct input of the IH Regional Quality Improvement working group. Page 3 of 33

4 2.0 SSC Regional QI Initiative The Specialist Services Committee introduced the RQI initiative in 2014 after considerable planning and discussion with the Ministry of Health and the health authorities. These discussions revealed that there was an opportunity to strengthen the focus on quality improvement by engaging specialists and providing them with a chance to be part of health authority quality programs and structures. Many health authorities indicated that while clinical and administrative staffs do participate in quality efforts, it was a challenge to bring physicians to the table. The SSC s Regional Quality Improvement (RQI) funding provides $1.3m annually per health authority, to address gaps in quality structures relating to physician participation in QI activities and to ensure those physicians have adequate technical supports. SSC has deliberately not defined what this opportunity should look like for the health authorities; rather, it is working with each health authority to tailor RQI to its unique needs using a grassroots, collaborative approach. Moreover, the SSC investment could exceed $1.3m, depending on each health authority s needs and the value demonstrated to SSC. The following provides an overview of the intended use of the funds: $100k for the SSC Leader Health authority hired staff resources to support coordination of the SSC Initiatives. $700k for Regional QI Team Health authority hired dedicated technical staff resources, such as Data Analysts, Quality Improvement Advisors, Coordinators, Evaluation Specialists, etc. $500k for physician participation in quality improvement within the health authority. Page 4 of 33

5 3.0 Engagement with Interior Health In May 2014, SSC representatives met with Dr. Jeremy Etherington, Vice-President Medicine & Quality, and other leaders (Dr. Michael Murray; Dr. Alan Stewart; Linda Comazzetto) to introduce funding available to establish a SSC RQI initiative within IH. In early 2015 discussions with Dr. Michael Murray continued until April at which time the role was transitioned to Dr. Ron Collins. In June 2015, SSC representatives meet in Kelowna with senior health authority leaders. IH expressed strong interest to participate in initiative. Both Dr. Collins and Aman Hundal were delegated the responsibility of developing a proposal, which included securing feedback from grassroots physician champions. A time limited Working Group (WG) was formed in March 2016 with representation from SSC, IH and the Ministry of Health. Interior Health Physician Champions Specialist Services Committee Dr. Ron Collins James Chan Gina Sloan Dr. Todd Ring Dr. Chris Baliski Dr. Scott Smith Dr. Kevin Stevenson Dr. Dwight Ferris Dr. Jeanne Mace Dr. Nattana Dixon-Warren Dr. Trevor Janz Dr. Gordon Hoag Ryan Murray Aman Hundal Regional QI Working Group Membership EMD, Quality and Patient Safety Corporate Director, Quality, Risk & Accreditation Corporate Director, Medical Affairs Network Medical Director, Emergency Medicine General Surgeon (Kelowna) Hospitalist (Kelowna) Psychiatrist (Vernon) Internal Medicine (Kelowna) Family Practice (Kelowna) Family Practice (Salmo) Family Practice (Nelson) Doctors of BC, Physician Representative SSC & SCC Ministry of Health Representative SSC SSC - Staff Representative To ensure the RQI initiative is developed collaboratively with input from key stakeholders, IH and the SSC created and signed a Letter of Intent on July 15, Please refer to Appendix A for a copy of the Letter of Intent. During the summer of 2015, Dr. Collins commenced a comprehensive engagement plan to connect with both formal physician administrative leaders and informal physician champions to understand what the key challenges and opportunities are with respect to improving quality. The information gathered from meetings, in-person and telephone one-to-one discussions, along with the work that Dr. Michael Murray developed was shared with the WG in March The WG met over the next few months to develop the RQI proposal. The WG feels confident that this proposal meets IH s needs to support physician integration into quality improvement initiatives effectively and efficiently. The WG supports presenting the proposal to the MQSLT and Health Authority Medical Advisory Committee (HAMAC) for feedback and endorsement. Page 5 of 33

6 4.0 Working Group Discussion 4.1 Overview Summary The IH RQI Working Group (WG) was tasked with development of this proposal. They met in person and by teleconference and undertook a Delphi process to further develop this proposal. The Ministry of Health have articulated five key priorities as part of an overarching plan to redesign healthcare delivery in BC. IH has a mandate to ensure that our activities are aligned with these five key priorities, each of which has a timeline and goals (please refer to Appendix B). The membership of the WG was diverse in terms of geography and specialty, and was specifically configured to reflect the five key priorities. The key themes that emerged at the WG include: Alignment of IH s existing quality work with RQI Recent IH reorganization and leadership changes, opportunities for RQI What is the current IH quality portfolio, focus, resources, etc RQI Goals and Objectives Lack of physician QI education and training Need to provide a number of diverse opportunities to allow physicians to participate in QI activity o Smaller and larger physician positions o Opportunity to do Unit Based Activity ; Physician Driven Projects ; Quality Reviews RQI Proposed model and budget requirements 4.2 Alignment / Structure IH made it very clear that the RQI initiative would have to fit within the existing quality structure to ensure that where possible there is alignment and effective use of resources. Specifically, linking the work with the existing local quality committees and aligning with the five key strategies of the Health Authority, as mandated by the Ministry of Health. Given that funding for the RQI is from outside the organization, it was noted that the governance structure would need to be modified to ensure all stakeholders have representation. Physician Quality Leads (PQL) will report to the Executive Medical Director, Quality & Safety and will become members of the local quality committees as appropriate. IH has several clinical Networks in the Quality Risk and Accreditation portfolio with a mandate to support QI; to this point the QI work of the Networks has been limited to supporting CCMs and practice standardization. It is to be noted that the Network Medical Directors also have a reporting relationship to the Executive Medical Director, Quality and Patient Safety. The Networks represent a direct mechanism to connect with frontline clinicians and act as a driver of innovation and quality improvement; we recognize the need to align the activities of the RQI (participating physicians) with the Networks as applicable and will adjust their Terms of Reference (TOR) to enable this. 4.3 Interior Health Reorganization IH has undergone a recent realignment of its Senior Executive Team under the direction of the newly appointed CEO. These changes are designed to capitalize on ongoing work to improve the patient experience and patient journey; and to continue to integrate services across multiple service delivery portfolios. The realignment also supports a MOH mandate to accelerate the shift in care from acute and residential facilities, to community programs and services. The Medicine and Quality portfolio, led by Dr. Alan Stewart, is tasked with further enhancing integration and accountability for achieving operational and strategic deliverables. Under Dr. Stewart s direction, the portfolio provides leadership to the organization in the areas of Quality, Medical Affairs, Clinical Networks, Infection Prevention and Control, and Physician Leadership. Page 6 of 33

7 4.4 Current Interior Health Quality Portfolio The existing Medicine Quality structure includes Medical Leadership, Medical Affairs, Clinical Networks, Quality and Infection Control. The networks each have a Network Medical Director, a Director and a Clinical Nurse Specialist; they have a quality mandate, and access to quality consultants from the QRA portfolio attached. The work of the networks is organized around demands from outside the health authority; these may be quality assurance activities such as CCMs and benchmark reporting. They have been limited in their ability to engage physicians/specialists in quality improvement activities even though they have extensive influence clinically with frontline care providers. Until recently the networks were somewhat isolated from the quality committees so we have reorganized their reporting relationships; now all of the Network Medical Director roles report to the Executive Medical Director, Quality and Patient Safety to ensure that our quality expectations can be matched with quality resources. The quality risk and accreditation department (QRA) consists of quality consultants, patient safety investigators, a human factors analyst, patient care quality officers, risk management specialists and adult guardian leader. The staff is spread throughout the organization to support all of IH s operations including; acute sites, community, and residential services with the majority of staff located in Kelowna and Kamloops. For more information please refer to Appendix C. 4.5 Goals / Objectives The intent of the RQI initiative is to provide a structure to support physician QI training, discuss quality issues, and act on opportunities for quality improvement activities that enhance patient care. The following list captures the key goals and objectives: 1) To promote a culture of Quality Improvement among physicians of IH; 2) To ensure the application of principles relating to Patient Family Centered Care (PFCC), Evidencebased Medicine, interdisciplinary teamwork, learning for improvement, leading change; 3) To create the capacity and capability for physicians to lead and participate in sustainable quality improvement; 4) To support the needs of physicians to enable improvement in the delivery of care; 5) To engage the medical staff by working collaboratively with IH s leadership; 6) To actively seek input and participation from patients in physician quality activities; To ensure quality activities seek to promote the IHI Triple Aim: a) Improve the patient/provider experience of care (including quality and satisfaction) b) Improve the health of populations c) Reduce the per capita cost of health care 4.6 Proposed Model Funding from external sources is typically includes many conditions and constraints, and often one is told how that funding can and cannot be used. In this case, very few parameters impeded the discussion, allowing rich dialogue and creative brainstorming of possibilities. With the launch of any new idea, that there is a certain amount of risk and probability of failure. Using the Plan-Do-Study-Act (PDSA) approach, it is anticipated that the proposed model will undergo review and alterations over time to ensure feedback from the deployment is used to continually improve the initiative. Page 7 of 33

8 There are a few key components of the Proposed Model that complement each other to create an integrated solution to support physician-led QI in IH. These components include funding to be allocated towards: Training QI Staff Physician QI Leads Physician QI Champions Physician QI Training The WG felt that resources for education and training need to be made available and these resources should be varied and flexible. There was a request for access to IH ilearn modules where participation could occur when time allows accommodating busy lifestyles. There was interest in pursuing resources available through IHI Open School, and a request for subscription to enable that. The group felt that a nine day course such as that offered by the BCPSQC (Clinician Quality Academy) might be too demanding for most physicians, especially those in rural locations. However, depending on uptake and further engagement, there may be interest to do a local cohort in IH. It should be noted that the QRA Department has offered to support the delivery of tailored training to physicians as needed. The WG agreed to explore and learn from other health authorities as it relates to physician QI training. It is clear to those who have received QI training and those who have been working in this field that in general physicians require QI training to be successful in addressing quality concerns. The WG believes QI training opportunities can also be used to understand general interest among the physician community and to identify keen participants. The WG suggests that a number of training options be provided to allow physicians to choose which option meets their unique circumstances, including in-house locally based training or supporting attendance at QI Training elsewhere. An initial budget of $65,000 is required to address the training gaps. This funding will not be used for sessional time unless specifically approved by SSC. When the RQI initiative launches, the WG proposes to hold a broader QI group training session to help identify physicians who are interested in QI. During these training sessions, the RQI program would be promoted, so that physician knows how to bring forward QI ideas. A number of training options were discussed by the WG, including: BCPSQC s New Clinician Quality Academy (to be delivered locally in IH) PMI courses, (in-house) IHI Online Training Page 8 of 33

9 Some of the above training options are funded by the Joint Clinical Committees and these existing options would be leveraged prior to using any of the $65,000 training budget. A secondary benefit of this approach ensures that physicians receive similar training when possible, and are able to use standard techniques and terminology as they work on their QI projects Physician QI Participation The WG discussed at length the passion and interest of physicians within IH to participate in QI activity. There are a lot of good ideas that need to be supported in a structured manner. The WG also suggested that multiple paths and opportunities be presented as not one solution will work for the physician community. Moreover, these opportunities need to be flexible to accommodate small and large projects, with the goal of using small projects and opportunities to draw more physicians into RQI, where the smaller projects then can grow into larger projects. A key example of a SSC supported projected that started small in one IH community and has successful expanded provincially is the Enhance Recovery After Surgery (ERAS) projects. In cases, where physician s are able to provide a larger commitment (i.e. 1 day per week, 0.20 FTE), formal positions Physician QI Lead will be created. In cases, where physicians are not able to allocate that much time and want to work on smaller projects and/or QI activity that session funding will be provided for positions called Physician QI Champion. Key points of discussion/agreement among WG members for the Physician QI Lead positions: The WG members were very sensitive to the issue that physicians may not be able to commit to a 0.1 or 0.2 FTE position as Physician QI Lead without impacting clinical service delivery, especially in more rural locations and we would anticipate that most of the Physician QI Lead positions would be filled by urban candidates where staffing levels will not impact service delivery. Recruitment should be based not on geographical diversity, but based on commitment and passion for quality. The WG felt that such leaders would be able to influence rural settings with quality improvement initiatives. It was emphasized that when setting up meetings IH staff and physicians need to work collaboratively and be flexible to accommodate the needs of each party and set meetings accordingly, understanding that in general staff prefer meetings during business hours whereas physicians provide patient care and would likely be available either early morning, or late evenings. The WG specifically identified MHSU and Residential as areas where Physician QI Lead positions would be useful and influential. The emerging picture for the Physician QI Lead positions from the deliberations of the WG is that these would predominantly involve physicians in urban settings along the Central Okanagan corridor and in Kamloops. Allocation of RQI staffing positions would need to reflect that. Key points of discussion/agreement among WG members for the Physician QI Champion positions: Sessional funding will be made available to select physicians to participate in QI activity. These physicians may choose to participate in QI activities led by the Physician QI Leads. These other activities must be focused, local and approved by the Joint Steering Committee. These physicians would have access to the technical RQI staffing resources to support their QI activities. Given many physicians make use of Medical Students who may wish to work on QI projects, this money could be used to support participation of Medical Students by funding any out of pocket costs such as travel expenses but not to provide funding for Medical Student time. We would also anticipate some mentoring activity to emerge from this pool of physicians. Page 9 of 33

10 Decision: The WG proposes that the RQI funding be used to support the creation of: One (1) Physician QI Advisor position to help support the coordination of the RQI file, provide leadership, mentoring and coaching to Physician QI Lead/Champions. The Advisor will also be expected to lead a QI project and participate in all QI training. They would also participate at the Joint Steering Committee and provincial RQI meetings. Seven (7) Physician QI Lead positions that each would be resourced to the equivalent of 0.2 FTE or 7.0 hours per week. A $75,000 broader sessional fund to be used to support QI activities for an additional twenty five (25) Physician QI Champions. Funding per physician would be initially capped at a maximum of $3,000 per physician, however the Joint Steering Committee would have discretion to modify and make exceptions. This fund may be increased depending on the level of interest from physicians. Recruitment of all positions will aim to ensure where possible the allocation is reflective of IH s geography. At first glance the broader sessional fund may appear to be similar to the Physician Engagement in Health Authority Redesign Fund that is provided by the Joint Clinical Committees. However, these are in fact different. The Physician Engagement in Health Authority Redesign funds are provided to IH to ensure funding is available to support physician participation in change or redesign projects led by the health authority Physician Engagement Opportunities/Examples As mentioned the WG wanted to ensure that physicians are offered different opportunities to participate in quality initiatives. This diversity and flexibility of opportunities will be important in understanding what physicians prefer, more importantly allowing them the space and autonomy to learn QI principles and apply knowledge in a setting/approach they desire and are comfortable with. It is envisioned that offering a range of flexible opportunities to engage in QI activity will support progressive engagement of physicians who may initially be unwilling to commit significant resources of time and energy, but over time may increase their QI training and commitment to more significant efforts and focus in an escalating fashion. In no particular order of preference or priority, the opportunities include: i. Physician Driven QI Projects: Many physicians have ideas for quality improvement but limited resources of time and expertise to drive these projects. They are often frustrated in their attempts to navigate the organizational structure of IH to mobilize support for their ideas. A specific example of this type of initiative in IH is Enhanced Recovery After Surgery (ERAS) which evolved into an SSC supported provincial collaborative but started as a physician driven pilot project. Despite that success, physicians can often be frustrated in their attempts to navigate the organizational structure of IH to mobilize support for their ideas. The WG supported the concept of assisting physicians to develop these ideas into short term focussed special projects ; we have developed a one-pager form to bring these ideas forward. This process would identify the opportunity (clinical problem), the leader, and the proposed approach to QI, the timeline, the metrics, the resources required and the end goal. Analysis of opportunities would be based on comparing impact versus complexity, and alignment with IH Quality strategy. We would emphasize the potential value in refocussing physician culture toward continuous quality improvement. o Mentoring/Support: Depending on the scale and complexity, the Physician QI Champions would be paired with Physician QI Lead to support them. Page 10 of 33

11 o We have developed a draft form to facilitate development and submission of these ideas. Please refer to Appendix D. ii. Physician Performance Enhancement Project: IH has a successful and expanding PPEP in progress in our Emergency Departments. This project started as a Sauder Physician Leadership Program project. This approach has been successfully applied to many other clinical physician groups in other health regions; we would network with established programs and projects to guide our efforts. A key element to the success of this initiative is data collection and analysis and reporting which would be supported by quality data analysts. We would recruit supported leadership from willing groups of physicians to seek to implement PPEPs more widely. iii. Quality Reviews: Physician would conduct periodic formal Quality Reviews based on issues identified within the organization from our adverse event response system, from our program or network directors, from physician leaders across the health authority, Quality staff or from themselves. Site identified challenges in provision of consistent, safe patient care emerges through our adverse event reporting system (PSLS), but this system does not typically capture and drive the effort to embrace evidence-based practice at the department level. We would support the application of a formal quality review process to drive quality improvement around the evolution of standardized practice at the department level. Funding would be allocated on a case by case basis to physicians trained to perform quality reviews. o These Reviews would seek to generate recommendations bringing evidence-informed best practice to the frontline, with the assistance and support of the networks and/or other clinical services or portfolios, to reduce unwanted clinical variation in physician practice. o Recommendations emerging from these quality reviews could be spread to front-line clinicians across the health authority through the activities of the IH Networks. o Recommendations would then be presented to Quality Committees at the site level, and through the appropriate Network and/or Program. o WG understands funding is for QI and not QA; Quality Reviews needs to be QI related. iv. Unit Based Quality Initiatives: Facility based specialists are often closely aligned with activity on one unit (ICU, ED, surgical ward, medical floor, etc.) We would like to support specialists and GP s to work with the personnel on their unit to identify hazards and safety opportunities and strategize efforts to mitigate them. It has not been typical for physicians to lead these efforts in the past so this would be a new model. Many physicians have a home base for their clinical activities; this could be a clinic, a medical or surgical ward, an ED or ICU. The WG endorsed the idea of supporting such physicians to work with front line staff on these units to identify and pursue quality improvement opportunities in a focussed, short-term manner. The opportunity to scale up and spread successful projects is recognized. A model for this work in IH is the Quality Improvement & Patient Safety (QIPS) program at RIH; elsewhere in the province, the Comprehensive Unit-Based Safety Program (CUSP) embraces a similar approach. v. Other/Partnership: Key areas of opportunity for integrating physicians into quality improvement in IH have been identified by the working group and by wider consultation with both physician leaders and administrators at the site level. These include MHSU, supporting community care of patients with chronic conditions through access to specialist support, transitions in care between community and acute, residential and acute, between units in acute, in escalation of care between sites (including MHSU) and in engaging Enhanced Recovery in trauma care. On a unit level, every physician seems to recognize that issues relating to patient safety and the reliability of care exist, and many would welcome the opportunity to engage in dealing with those issues. Page 11 of 33

12 The following figure illustrates how the above QI opportunities can be utilized by Physician QI Leads and Champions. Physician Driven QI Project + Training (i.e. 9 days) Physician QI Roles (1 Advsior, 7 Leads) Mentor/Support (Physician QI Champions) PPEProject Sessional Funding Physician Driven QI Project SMALL (intake process) Physician QI Champions ($75,000) Quality Reviews Unit Level Projects Technical QI Team Dedicated staff resources are required to support the efforts of the Physician QI Leads and Champions. These resources would be embed and integrated within IHs existing structures. The staff would be technical in nature, each bringing key skills and abilities to form a QI Team. These resources would primarily support RQI activities and would require SSC approval prior to being deployed for any other health authority need. The QI Consultants would report into the existing Area Managers for West and Central/East for the purposes of integrating the new RQI staff with existing Quality Staff. Among the 3 QI Staff one of the positions will be utilized to participate on provincial meetings. The QI Coordinator would provide administrative and project management support to the team. The WG proposes the following roles: Position Title Range FTE Data Analyst QI Consultant (West, Central, East) QI Coordinator Page 12 of 33

13 In addition, the Technical Team will require funding to tap into specific skills and abilities in the form of evaluation support. The role of Evaluation, Health Economist is somewhat novel, but worthy of addition to the evaluation side of an initiative like this. We suffer from the curse of pilot projects that demonstrate success and then struggle with scaling up. We recognize the need for continuous Return on Investment/Cost-Benefit analysis to support quality improvement. This is work that will not likely be successful in the hands of physicians. The SSC expects that all of its funded activity can be measured to illustrate its impact on health outcomes. The WG proposes the following funding: Funding Supports FTE Evaluation (Health Economist) 0.5 Please refer to Appendix E where details of each role has been provided. Note these are approved HEABC existing job descriptions that will be modified with input from the Joint Steering Committee Budget After considerable input and deliberations, the WG believes funding of $1.22m will be sufficient to implement the RQI program in a meaningful manner. The WG understands the SSC will provide the following budget commitment up to March 31, The following table provides a high level breakdown of the funding request. FTE Qty Rate Benefits Sub-Total Total Physician QI Advisor $148.31/hr $53,984 Physician QI Leads $148.31/hr $377,893 Physician QI Champions - 25 $148.31/hr $75,000 QI Training & Supports $65,000 Sessions Sub-Total $571,877 Data Analyst (R7) $77,454 27% $98,367 QI Consultant (R8) $90,948 27% $346,511 QI Coordinator (R5) $65,037 27% $82,596 Evaluation (Health Economist) 0.5 $50,000 Staff Travel $20,000 Other (Patient Expenses, Training, Food, etc) 15,000 QI Resources Sub-Total $612,474 Sub-Total $1,184,352 Infrastructure Support (2%) $23,687 Grand Total $1,208,039 Page 13 of 33

14 4.6.6 Timeline The WG is planning to bring forward this proposal to the SSC for approval in Jan Once the proposal is approved the selection and recruitment of physician leaders and champions is expected to take a few months. While the WG is aware of potential demand, specifics are difficult to determine until the physician community is engaged. The following table provides a summary of the key milestones. Target 2017 January SSC Endorsement 2017 February/March Form Joint Steering Committee Recruit Technical Team 2017 May Hold four (1) day training sessions 2017 June Recruit Physician QI Advisor Recruit Physician QI Leads 2017 September Communicate Broader QI Sessional Supports (i.e. Physician QI Champions) 2017 October First 6 months report out of activities (Presentation to SSC) Task Page 14 of 33

15 5.0 Governance and Reporting The WG had an in-depth conversation on optimal deployment of this opportunity. As stated in section 4.2 Alignment/Structure, any proposed structure would need to be embedded in existing IH structures but the governance model would be developed in collaboration with SSC along with representation from IH. This allows the structure to indirectly fit into IH and align and work well with the direction IH has set in their recent geographic leadership realignment but at the same time have the autonomy it needs to flourish. The placement of this funding in IH is crucial to the optics and uptake from the physician community. The WG proposes establishing an ongoing Joint IH/SSC RQI Steering Committee to provide oversight with respect to the use of funds, outcomes and deliverables. All decisions would be made through consensus. The Steering Committee would provide timely updates (i.e. quarterly basis) to IH via the Executive Medical Director, Quality & Patient Safety and to SSC via the SSC staff representative. To strengthen the linkages with other QI initiatives and strategic priorities, it is suggested that the Steering Committee will also present regularly to the other leadership tables and quality committees tables across IH. This Steering Committee would be comprised of: Organization # of Representatives Interior Health 4 to 5 Physician Champion 3 to 4 Specialist Services Committee 2 Suggested Roles EMD, Quality and Patient Safety EMD, Geographic Area Corporate Director, Quality, Risk & Accreditation Senior Operations Leader (SAO) or designate HAMAC Chair or designate Physician QI Advisor Medical Staff Association President Divisions of Family Practice Lead Clinically Active Physician Physician Representative SSC Staff Representative Patient Representative 2 Aim to cover geographic region where possible Page 15 of 33

16 6.0 Appendices 6.1 Appendix A Letter of Intent Page 16 of 33

17 Page 17 of 33

18 Page 18 of 33

19 6.2 Appendix B Five Key Strategies Page 19 of 33

20 6.3 Appendix C IH Quality Structure Vice President Medicine and Quality Organization Chart Page 20 of 33

21 6.3.2 Quality, Risk & Accreditation Organization Chart Page 21 of 33

22 6.3.3 Critical Incident Review Team Reporting Structure Local Quality and Patient Safety Committee Terms of Reference Page 22 of 33

23 Page 23 of 33

24 Page 24 of 33

25 Page 25 of 33

26 Page 26 of 33

27 6.4 Appendix D Physician Lead Quality Project Template DRAFT SAMPLE OLNY Physician Lead Quality Project Template Project Name Project Lead Site-Area Date Contact Contact Phone Current State (issue) Approach Deliverables Timeline & Milestones Additional Resources Relevant literature (couple references) Other Comments Page 27 of 33

28 6.5 Appendix E Job Descriptions Job Title: Quality Improvement Consultant JOB SUMMARY: In accordance with the established vision and values of the organization, the Quality Improvement Consultant is responsible for providing leadership and expertise in the application of quality improvement principles, practices, and tools in support of clinical program priorities within the Quality, Risk and Accreditation Department across Interior Health. The Consultant promotes the integration and standardization of evidence-based systems and tools as identified, and in alignment with, the QRA Strategic Plan. The Consultant works with the Quality Team to evaluate goals and objectives identified in the Quality work plans. The Quality Improvement Consultant may also be responsible for participating in serious incident reviews and providing reports and recommendations for action arising out of incident investigation. As an integral member of the Interior Health Quality, Risk and Accreditation Department, the Consultant collaborates with health care leaders, managers, and physicians to provide leadership and expertise in the planning, implementation, and evaluation of improvement initiatives designed to improve quality of care, service utilization, safety, and risk reduction to produce measurable outcome results. TYPICAL DUTIES AND RESPONSIBILITIES: 1. Provides leadership and expertise to promote a culture of quality improvement. 2. Facilitates the integration of quality improvement initiatives that can be monitored and measured using reliable data. 3. Collaborates with leaders, physicians, and staff to provide leadership and quality improvement expertise to local community teams in the planning, implementation, and evaluation of quality initiatives designed to improve patient-centred care, service utilization, patient safety, and risk reduction. 4. Aligns and integrates improvement efforts with IH quality service teams, programs, and networks. 5. Identifies and assesses site-based quality improvement needs related to the integration of quality improvement methodology, evidence based systems, and tools within everyday work processes. 6. Maintains, monitors, and analyzes quality data and supports the collection of this data. 7. Initiates and implements methods of improvement aligned to the Quality Risk/Accreditation strategic plan and priorities. 8. Monitors performance indicators across the continuum of care utilizing Quality management principles, concepts, tools, and methods. 9. Works with other members of the QRA Department as appropriate to support the implementation and evaluation of the BC Patient Safety Learning System for incident reporting. 10. Completes assessment of QI processes, ensures that standards are in place, and advises on changes required (e.g. compliance with Accreditation Canada Standards). Page 28 of 33

29 11. Provides facilitation, coaching, and support to teams in the development, monitoring, and analysis of key performance indicators in alignment with other levels of reporting in Interior Health. 12. Performs a leadership role in the integration of accreditation principles and standards with local initiatives. Coaches and facilitates teams participating in Interior Health programs, networks, and services in accreditation self-assessment, planning, and survey preparation and follow-up. 13. Contributes to the development and review of policies and guidelines related to patient safety and the quality of care. Provides expert advice to leaders, as needed. 14. Performs other duties as assigned. QUALIFICATIONS: Education, Training and Experience Master s degree in a health related field Two to five years recent clinical experience in health care services required Educational preparation in quality improvement and patient safety Three years progressive management experience Or an equivalent of education, training, and experience Competencies Interior Health Emotional Intelligence Competencies Leadership: building a team environment, communicating clearly with all levels of staff Leading Change: promoting and encouraging innovation, ensuring that all staff are aware and prepared for upcoming changes Achievement Oriented: demonstrating accountability for all areas of responsibility Business Acumen: managing resources, possessing health environment and political awareness Systems Thinking: ability to see the overall IH perspective, while maintaining focus on specific initiatives within the HSA Communication: ability to communicate with all levels of staff, from Senior Leaders to front-line staff Skills and Abilities Ability to communicate effectively, both verbally and in writing Demonstrated knowledge of quality improvement principles, methods, and tools Demonstrated leadership skills Demonstrated ability to communicate effectively with others at all levels of the organization Demonstrated skills in facilitation, presentation, and teaching skills Demonstrated ability to develop and maintain effective working relationships with a variety of stakeholders Ability to operate related equipment and proficiency in the use of computer software Must be familiar with quality improvement methods, tools, and software, such as Microsoft Word, SharePoint, Excel, and PowerPoint Job Title: Statistical Analyst Page 29 of 33

30 JOB SUMMARY: In accordance with the established vision and values of the organization, the Statistical Analyst is responsible for supporting the development and implementation of statistical data collection, indicator development, and reporting within Interior Health (IH). Primary responsibilities include: development and completion of key indicator reports and supporting analyses to inform planning and decision-making for the organization; implementation of the national MIS chart of accounts; and analysis of key indicators. The Statistical Analyst provides input to IH statistical reporting standards, policy development and interpretation, and the development and application of related definitions. The Statistical Analyst provides guidance and expertise to the Manager, Statistics & Performance Reporting and the Director, Information Management. TYPICAL DUTIES AND RESPONSIBILITIES: 1. Provides input to and makes recommendations to the Manager, Statistics & Performance Reporting on statistical indicator reporting issues as they relate to the collection and reporting of key indicators, data, and benchmarking within IH. 2. Provides timely, relevant, reliable, and clear information with appropriate supporting data analyses and review of alternatives to inform planning and decision-making. This will include service utilization; statistical trending; and outcomes analyses and information for use by facilities planning, senior leadership, program managers, and healthcare providers, as well as public information. 3. Plans, recommends, and develops data collection systems, processes, and standard reporting across the region. Coordinates reporting from feeder modules (Admissions, Diagnostic Laboratory and Radiology, module, and other source systems) ensuring accurate and efficient data capture, automation, and standardization across IH. 4. Formulates, develops, and maintains statistical reporting, benchmarking, and trend analysis in consultation with or in response to requests from staff at all levels within the organization or from external sources, such as the Ministry of Health Services (MOHS) and/or Canadian Institute of Health Information (CIHI). 5. Reviews statistical data for compliance with standards of completeness, accuracy, and data quality within the guidelines of IH, MOHS, or CIHI. Performs analysis and reconciliations comparing other databases with MIS and ensures integrity of reporting. Identifies source of anomalies, recommends solutions. 6. Develops a strong working relationship with program managers, directors, senior executive, business support, and others who require information for planning, managing, and evaluating services. Project support may include planning project deliverables and identifying data sources and appropriate methods to support planning, data analyses, writing summary reports, and preparing presentations. 7. Works with provincial and national representatives on statistical and strategic information projects. This may include work with the CIHI and MOHS priority initiatives. The focus of this work will be to review key assumptions and methods, evaluate and provide input to measures and data definitions, provide data, and assist with interpretation of findings. Page 30 of 33

31 Provides liaison with provincial MIS coordinator on upcoming changes to the national and provincial chart of accounts. 8. Provides input to IH statistical reporting standards, policy development and interpretation, and the development and application of related definitions. 9. Develops reporting and data collection systems for job action data, job action status, and related issues. During job action, implements collection of essential data and impacts for job action management, overseeing the daily collection and reporting of data along with HSA issues. Prepares daily reports for the Ministry, senior management, and strike committee. 10. Coordinates department work assignments and provides supervision to staff, as the alternate contact for the departmental manager. 11. Maintains the statistical MIS chart of accounts and implements updates to the chart as required. Coordinates update of related indicator reports. 12. Coordinates data quality improvement projects. Formulates and develops standards in consultation with external and internal contacts and redesign teams. 13. Represents IH on various committees and task forces as required. 14. Performs other duties as assigned. QUALIFICATIONS: Education, Training, and Experience A University or professional degree in Business, Math, Accounting, or Health Records or an equivalent combination of education, training, and experience. Three to five years progressive experience working in a complex, computerized environment. Knowledge of CIHI MIS Guidelines preferred. Competencies IH Emotional Intelligence Competencies Skills and Abilities Demonstrated ability to lead, plan, direct, manage, and implement. Ability to work under the pressure of deadlines. Demonstrated ability to function effectively in a highly dynamic environment. Demonstrated ability to communicate effectively, including the ability to make presentations to groups. Strong interpersonal skills. Demonstrated ability to be effective in an environment subject to continuous change. Excellent knowledge of current healthcare issues. Physical ability to perform the duties of the position Job Title: Strategic Information Analyst Page 31 of 33

32 JOB SUMMARY: The Strategic Information Analyst will be responsible for supporting strategic information planning, analysis, and decision support within a defined portfolio. The Analyst will be part of the Information Management Department but will work closely with the manager or lead of the assigned portfolio and key internal stakeholders. TYPICAL DUTIES AND RESPONSIBILITIES: Provide timely, relevant, reliable, and clear information with appropriate supporting data analyses and review of alternatives to inform planning and decision-making. This will include population, service utilization, and outcomes analyses and information for use by facilities planning, senior leadership, program managers, and health care providers as well as public information. Provide data analysis using key data sources (population, clinical, organizational, and administrative) in response to strategic and corporate services, senior executive, and program level requests for information and analysis. This work may include data linkage, descriptive information, statistical analyses, and statistical tests of significance. Review planning and evaluation documents as well as plans for allocating resources and provide appropriate information and feedback. This will include health services plan and program planning documents prepared by IH Health Services planning, Facilities Management, and program staff. Information and feedback will include providing assistance with population and utilization data as well as feedback on planning assumptions. Provide input and identify opportunities for information support activities to the Director, Information Management. This will include providing suggestions and advice on important data development and future projects/analyses. Develop a strong working relationship with program managers, directors, senior executive, business support, and others who require information for planning, managing, and evaluating services. Project support may include planning project deliverables and identifying data sources and appropriate methods to support planning, data analyses, writing summary reports, and preparing presentations. Respond to data and information requests from staff at all levels of the organization. Provide support and technical advice to staff on the use of strategic information resources and applications. Work with provincial and national representatives on strategic information projects. This may include working with the Canadian Institute for Health Information and Ministry of Health priority projects. The focus of this work will be to review key assumptions and methods, provide data, and assist with interpretation of findings. Page 32 of 33

33 Work with representatives of other Health Authorities and other data custodians to support strategic information, analysis, interpretation, and reporting initiatives. Provide advice, analysis, and recommendations on initiatives related to data collection, database development, and data extraction and analysis to Information Support & Research. Work with Information Management/Information Technology and other IH staff to support timely, reliable, and consistent data reporting and analysis. QUALIFICATIONS: Education, Training, and Experience Post-secondary degree with completed course work in a health-related discipline, and/or an equivalent combination of education and experience. A Master s degree is preferred. Preference will be given to a candidate with a strong health information management background including health records training Experience working in a complex computerized environment Minimum of two years experience of data management, linkage, analysis, interpretation, and reporting Competencies Interior Health Emotional Intelligence Competencies Skills and Abilities Teamwork and strong interpersonal skills due to the amount of communication required Collaborative leadership in order to both work as a member of a team and provide leadership in developing partnerships amongst multiple stakeholders Page 33 of 33