UTILIZING BEST PRACTICE METHODS TO IMPROVE LABOUR MANAGEMENT IN A PARTNERSHIP OF FIVE HOSPITALS

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1 UTILIZING BEST PRACTICE METHODS TO IMPROVE LABOUR MANAGEMENT IN A PARTNERSHIP OF FIVE HOSPITALS David E. Walker, Hon BSc, MD, CCFP Department of Obstetrics. Alexandra Marine and General Hospital. Goderich ON Abstract Objective: To assess the use of "Best Practice" methods as a means of improving obstetrical care pertaining to labour management and Caesarean birth in a partnership group of 5 hospitals, 4 with birthing rates of 50 to 175 women a year, and the fifth with a birthing rate of approximately 1000 women a year. Methods: The Labour Management module of the Advances in Labour and Risk Management (ALARM) Best Practice course of the Society of Obstetricians and Gynaecologists of Canada (SOGC) was tested on the 4 Level I rural hospitals and I modified Level II hospital in a small city in the Huron Perth Hospitals. The outcomes assessed were the module's effectiveness as a Continuing Medical Education (CME) tool; its effectiveness at promoting common practice guidelines; and its effectiveness at improving communication and co-operation. Results: From the 5 participating partnership hospitals, 3 obstetricians, 28 family physicians, and 5 midwives were eligible to participate. Of these 36 clinicians, 80% completed the Prestudy Phase, which included auditing their practice for Labour Management; 94% attended the workshops; and 67% completed the Post-study Audit. Common practice changes were identified through the workshops and post-study results showed success in their implementation. A Post-study Questionnaire indicated improved co-operation and communication in the partnership hospitals. Conclusions: The Management of Labour module of the SOGC ALARM Best Practice course was successful in improving obstetrical practice in the partnership group of hospitals tested. This method promoted the use of common practice guidelines at the bedside and also improved communication and co-operation in the hospital partnership. Resume Objectif : Evaluer Ie recours aux methodes de «pratique optimale» comme moyen d'ameliorer les soins d'obstetrique, en matiere de prise en charge de I'accouchement et de I'accouchement par cesarienne, dans Ie contexte de cinq hopitaux formant un partenariat, dont quatre pratiquaient de 50 a 175 accouchements par annee, alors que Ie cinquieme en pratiquait environ I 000 par annee. KeyWords Best practice, labour management. Caesarean birth Competing interests: None declared. Received on May Revised and accepted on March Methodes : Le module de prise en charge du travail faisant partie du cours sur les pratiques optimales, offert par Ie programme GESTA (Gestion du travail et de I'accouchement) de la Societe des obstetriciens et gynecologues du Canada (SOGC), a ete evalue dans les quatre hopitaux ruraux de niveau I et I'hopital de petite ville de niveau II modifie appartenant au reseau des hopitaux de Huron Perth. Les resultats evalues etaient I'efficacite du module en tant qu'outil de formation medicale continue (FMC), son efficacite en tant que moyen de promouvoir des directives de pratique communes, ainsi que son efficacite comme moyen d'ameliorer les communications et la cooperation. Resultats : Dans les 5 hopitaux de ce partenariat, 3 obstetriciens, 28 omnipraticiens et 5 sages-femmes ont ete admis a participer. Parmi ces 36 professionnels, 80 % ont termine I'etape precedant I'etude qui comprenait la verification de leur pratique en matiere de prise en charge du travail; 94 % d'entre eux ont participe a des ateliers; et 67 % d'entre eux ont termine la verification posterieure a I'etude. On a identifie les changements apportes aux pratiques communes au moyen des ateliers, et les resultats evalues en fin d'etude ont confirme Ie succes de leur mise en ~uvre. Le questionnaire de fin d'etude a permis de constater une amelioration du degre de cooperation et de communication entre les hopitaux du partenariat. Conclusions: Le module de prise en charge du travail faisant partie du cours sur les pratiques optimales, offert par Ie programme GESTA de la SOGC, a reussi a ameliorer les pratiques obstetricales dans les hopitaux du partenariat evalues. Cette approche a facilite Ie recours a des directives communes sur les pratiques adoptees au chevet des patientes et a egalement ameliore la communication et la cooperation au sein de ce partenariat. INTRODUCTION J Obstet Gynaecol Can 2003;25( 12): In June 2000, the Report of the Caesarean Section Working Group of the Ontario Women's Health Council (OWHC), Attaining and Maintaining Best Practices in the Use of Caesarean Sections, l identified "Critical Success Factors" including a pride in a low Caesarean delivery rate, a "culture" of birth as a normal physiological process, a commitment to one-to-one supportive nursing care during labour, strong team leadership, and a strong commitment to evidence-based practice. Based on these principles, a number of initiatives in Ontario hospitals were JOGC DECEMBER 2003

2 funded by the Ministry of Health and Long-Term Care and sponsored by the OWHC to conduct assessments and initiate changes that would contribute to "best practices" in the use of Caesarean sections. The Advances in Labour and Risk Management (ALARM) course 2 was initiated by the Society of Obstetricians and Gynaecologists of Canada (SOGC) in It has been developed, maintained, and presented collaboratively by obstetricians, family physicians, registered nurses, and midwives. The course is based on best evidence and incorporates Canadian guidelines and standards of practice. "Best Practice" courses are becoming a common method of Continuing Medical Education (CME). They are based on a rationale developed in Greene's PRECEDE mode1. 3 Participants first receive educational materials that predispose them to adopt a new practice, followed by enabling materials that help participants to bring the innovation to their practice, and, finally, an audit tool with which to collect feedback on the progress of the innovation in their practice. The work of Davis et al. 4 has demonstrated that educational sessions built around this model are more likely to result in physicians adopting changes in their practice than traditional didactic CME programs. The ALARM committee of the SOGC in 2001 developed for the ALARM course a Best Practice module in the Management of Labour (Table 1). Now in use, the pre-test and audit are completed prior to the workshop that occurs at the time of the ALARM course. The Huron Perth Hospitals Partnership (HPHP; now Huron Perth Hospitals) was created in It includes 8 hospitals in Huron and Perth counties in Southwestern Ontario. The 5 hospitals that provide obstetrical care are located in Goderich, Clinton, Wingham, and Listowel (all Level I) and Stratford (modified Level 11). With a population base of , the total number of hospital-based births among the HPHP was 1431 in the year Of the Level I hospitals, the smallest attends fewer than 50 births a year, 2 attend 100 to 150 births a year, and 1 attends 150 to 200 births a year. The remaining approximately 1000 births occur at the Level II hospital. The Caesarean rate for this hospital cluster was 15.3% in 2000 and ranged from 11.4% to 16% from 1995 to Prior to this study, there was no overall organization among the obstetrical departments, although there was linkage through the Perinatal Outreach Program of Southwestern Ontario. In the HPHp, there are 3 obstetricians, 28 family physicians, and 5 midwives. All obstetricians practise at the Level II hospital and are within 10 years of starting practice. Four family physicians and 4 midwives also practise at the Level II hospital. In the HPHp, more than 50% of the 28 family physicians are in or nearing late career, and 35% have been in practice for less than 5 years. Of the hospitals in the HPHp, only the Level II hospital has 24-hour Caesarean section capability. The Level I hospitals have Caesarean section capability most of the time, performed by general surgeons. Difficulty providing continuous anaesthesia or surgical coverage is the usual reason given in Level I hospitals for transfer of potential Caesarean births to the Level II hospital. The 4 Level I units serve rural communities and share the common goals and problems of all rural units in Canada. The Joint Position Paper on Rural Maternity Care 5 underlines the importance and safety of providing good obstetrical care as close to home as possible. Despite this, family physicians express concerns regarding their skill levels, whether they are at the end or beginning of their careers. The Management of Labour module of the ALARM Best Practice course has never been applied at the hospital level. This study examines the incorporation of Best Practice format for management of labour, contained in the ALARM course, as a means of improving obstetrical care in a partnership group of smaller hospitals. It also looks at whether applying the module at the hospital level promotes the use of common practice guidelines and improves communication and co-operation. TABLE I COMPONENTS OF A BEST PRACTICE COURSE Pre-assessment: including pre-test to assess knowledge and learning needs Audit of cases: reviewing cases in the participant's practice that reflect the subject of the Best Practice course Workshop: where participants can interact with a facilitator while discussing a clinical case or scenario illustrating principles and best evidence Commitment to Change - Part I: where participants are invited at the completion of the workshop to consider, list. and sign changes they might make in their practice Time period: during which these changes can be incorporated into their practice Post assessment Re-audit: including cases collected since the workshop Commitment to Change - Part 2: allowing participants to gauge their success in incorporating their committed changes into practice JOGC DECEMBER 2003

3 METHODS For each of the 5 partnership hospitals, a Clinical Leader and a Health Records Leader were identified. A pre-study meeting was convened with these individuals to brief them on the principles of the study and, in particular, the Best Practice model. The author acted as Study Coordinator. Each hospital's Clinical Leader identified the midwives, the family physicians who offered obstetrical care, and the obstetricians. The members of the "Study Group" were personally contacted by the Study Coordinator, given an explanation, invited to participate, and sent a pre-study package. All agreed to participate. The pre-study package included a needs assessment, with questions gauged to determine participants' usual practice in management oflabour issues and attitudes regarding Caesarean birth. Participants were requested to complete an audit of 5 labour and birth charts, using a provided audit form (Table 2). To facilitate the audit process, Health Record Leaders were responsible for pulling 5 charts, preferably with progress oflabour problems, from each participant's practice, and for placing an audit form with these for convenience. Prior to attending the workshops, the physicians, midwives, and nurses were responsible for completing the pre-study materials. The Management of Labour workshop from the ALARM TABLE 2 LABOUR MANAGEMENT, PRE- AND POST-AUDIT, REVIEW 5 CHARTS Active Labour Was cervix at least 3 cm dilated when diagnosed? Was onset charted clearly? Was hospital admission avoided prior to onset of active labour? Partogram used? Began plotting with active phase? Made decisions based on partogram? Was continuous one-to-one support provided during labour? Was ambulation and upright posture encouraged? Was appropriate analgesia used? Was assessment of fetal well-being by the preferred method of Intermittent Auscultation (IA)? If not, was electronic fetal monitoring (EFM) used routinely? Was dystocia identified correctly? ::::4 hours <0.5 cm/h dilatation or :::: I hour with no descent while pushing If so, was etiology considered and charted? What interventions were initiated? Amniotomy Augmentation with oxytocin dosing guidelines followed? Initial dose 1-2 mu/min interval every 30 minutes Dosage increment 1-2 mu EFM initiated? Were reassessments appropriately timed and recorded? Were cord gases performed? Did full discussion in your estimate occur throughout case? Was it recorded satisfactorily? Was documentation in your estimate complete? If Caesarean section was performed, was cervical dilatation >3 cm? Adapted and reprinted with permission from ALARM course materials, Society of Obstetricians and Gynaecologists of Canada. JOGC DECEMBER 2003

4 course was presented by the Study Coordinator, who acted as trainer and facilitator. Participants received workshop materials, including a labour scenario, a simplified partogram, Risk Management Strategy flowcharts for Labour Management and Dystocia, and a "Commitment to Change - Part 1" form. The workshops, each 90 minutes in length, were interactive and evaluated upon completion. Each hospital was given 2 bedside tools: a booklet, containing the Risk Management Strategies, and a simplified partogram. At the completion of the workshop, participants were invited to complete and sign the "Commitment to Change - Part 1," which allowed them to list up to 5 practice changes identified as a result of the pre-assessment and workshop, and to assign on a 5-point scale their level of commitment to incorporating these changes into their practice. A study period of 4 months was allowed, during which participants attempted to incorporate change into their practice and collected further cases for audit. Clinical Leaders were responsible for encouraging the use of the bedside tools to ensure that the same practice guidelines were being used. After 4 months, the post-study phase began, with a package sent to each participant. The package included a Post-study Questionnaire to assess the success of the Best Practice model, changes in practice, and communication and co-operation among caregivers; the 5-chart audit form; and a "Commitment to Change - Part 2" form, which listed the participant's original "Commitments to Change," to be assessed as to their successful incorporation into the participant's practice. Participants were reminded, both through written communication and personal telephone contact by the Study Coordinator, to maximize compliance. RESULTS BEST PRACTICE METHOD Table 3 summarizes the participation rates for each portion of the study: Pre-study Phase, Workshop, and Post-study Phase. Of the 36 participants in the study group, 80% completed the Pre-study Phase, 94% attended the workshops, and 67% completed at least the audit portion of the Post-study Phase. TABLE 3 PARTICIPATION RATE' Eligible Pre-study Workshop Post-study Birth Care Phase Phase Provider (Audit) n n (%) n (%) n (%) OBs 3 3 (100) 3 (100) I (33) FPs (86) 27 (96) 22 (79) MWs 5 2 (40) 4 (80) I (20) Overall (80) 34 (94) 24 (67) *OBs: obstetricians; FPs: family physicians; MWs: midwives. Thirteen members of the Study Group returned evaluations on the workshops, and all "strongly agreed" or "agreed" that the objectives were clearly communicated, the materials were useful, and the format was successful in developing ideas on ways to improve their management oflabour. The only weakness cited was the inadequate amoum of time allotted for discussion. Nineteen members (53%) of the Study Group responded to the questions pertaining to the Best Practice method contained in the Post-study Questionnaire, with all of them responding that they had achieved a good understanding of the method (Table 4). Comments included that the Best Practice method "keeps my knowledge current"; "unifies concepts amongst RNs, MDs across HPHP and leads to better outcomes"; "[makes it] easier to work with other team members"; and that the "self-evaluation of care [is] very enlightening." In the Post-study Questionnaire, respondents identified barriers that they experienced in completing the study. Time commitment for completing questionnaires and audits and the inconvenience of attending the workshop were moderately weighted. Lack of financial incentive and loss of financial gain were rated as less important. None of the 12 participants who failed to complete the Post-study phase responded to the "Barriers to Completion" Questionnaire. PROMOTING COMMON PRACTICE GUIDELINES Prior to the study, none of the units had practice guidelines at the bedside. Each unit had its own practice guidelines, but these were kept in procedural manuals. When asked to comment on whether an objective method from the Management of Labour workshop was utilized to aid decisions, the participants generally cited the use of a partogram. During the course of the study, the bedside tools, that is, the Management of Labour and Dystocia booklets, and the simplified partogram, were available at the bedside. Eight of 19 respondents listed as a benefit that "I knew everyone in my hospital was following the same guidelines" (Table 4). Only 1 listed as a benefit that "I knew that the other obstetrical units in the HPHP were using the same standards and guidelines." There were 24 who completed the "Commitment to Change - Part 1" (67% of Study Group) and 14 who completed the "Commitment to Change - Part 2" (40% of Study Group). The 5 most common changes that participants committed to were (1) to utilize a partogram; (2) to accurately diagnose dystocia and use the recommended augmentation protocol; (3) to use intermittent auscultation reserving electronic fetal monitoring (EFM) for recommended indications only; (4) to take cord gases at all births; and (5) to accurately diagnose "active labour." (Table 5). Their average commitment level ("Part 1") and the average success in implementation ("Part 2") are also included in Table 5. IOGC DECEMBER 2003

5 TABLE 4 RESULTS OF QUESTIONNAIRE ON THE BEST PRACTICE METHOD Post-Study Questionnaire Regarding Best Practice Method Number of responses (53% of Study Group) Rating Usefulness in Labour Management High Low to you 5 ~t 3 2 1* to your hospital 5 ~ 3 2 1* to HPHP group I Likelihood to improve outcomes, e.g., Caesarean birth rate, neonatal and maternal morbidity 5 ~ 3 2* I Benefits n (%) of Study Group I learned some things about my practice 13 (37) I knew everyone in my hospital was following the same guidelines 8 (22) I knew that the other obstetrical units in HPHP were using the same standards and guidelines I (3) Rating Barriers High Low time commitment I inconvenience to attend workshop I lack of financial incentive I loss of working time and financial gain I *Obstetrician respondent. tbold and underlined figures indicate the median response. TABLE 5 RATING OF COMMITMENT TO CHANGE Part I: Commitment Level Part 2: Success in Implementation Changes Responses Responses Committed to n (%) High Low n (%) High Low Utilize partogram 18 (75) 4 1* 2 I 13 (93) I Accurately diagnose dystocia. II (46) ~ 3 2 I 5 (36) I Use recommended augmentation protocol Use Intermittent 9 (38) I 6 (43) I Auscultation (la). EFM for recommended indications only Take cord gases at all births 8 (33) ~ 3 2 I 6 (43) ~ 3 2 I Accurately diagnose 6 (25) I 5 (36) I "active labour" *Bold and underlined figures indicate the median response. JOGC DECEMBER 2003

6 COMMUNICATION AND CO-OPERATION Table 6 summarizes the responses to questions pertaining to communication and co-operation. In the Pre-study Questionnaire, comments from the obstetricians included that "some transfers are late and some arrivals occur without adequate warning"; "quite different comfort and skills levels exist [in Level I hospitals] which can result in poor communication"; "guidelines or suggestions for safe practice are not uniformly adhered to." Several family physicians questioned whether the obstetricians supported rural units. Two midwives cited problems with access to physicians on-call, although 1 commented that there was "excellent teamwork and respect for each other's skills and appropriate consultation." Respondents to the Post-study Questionnaire regarding communication and co-operation gave no comment or wrote "Unable to make a comment." DISCUSSION highest participation. Evaluations were uniformly very positive. I believe the "Commitment to Change" was an important aspect of the study that can actively facilitate change in practice. The reduced participation rate in this section was possibly due to the reluctance of some of the subjects to commit to change in writing. By the Post-study Phase, the participation rates had fallen. The overall rate of return for the Post-study Audit of 5 further labour and birth charts was 67%. The Post-study Audit was considered the most important aspect of the study to reinforce change. Only 1 of the 3 obstetricians completed the Post-study Audit. Although all of the family physicians at 3 of the 4 Level I hospitals completed this audit, the overall family physician rate was 79%. The Post-study Questionnaire was returned by 53% of the Study Group, reducing its assessibility. Thirteen of the 19 respondents (68%), however, felt they "had learned some things about their practice" as the most important benefit of the Best Practice method. BEST PRACTICE METHOD I believe the Best Practice method was very eagerly accepted. The workshops, as CME events, were well-received, tailored for local participation, interactive, inclusive, and provided best evidence according to the ALARM program. The high level of participation reflected the dedication of the care providers, the appeal ofloca1ly provided CME events, and the structure of the Best Practice method. The workshops had the highest rate of participation and the Pre-study Phase had the next PROMOTING COMMON PRACTICE GUIDELINES Before this study, HPHP had no common practice guidelines in labour management, nor were there guidelines at the bedside. Partograms, although available, were not effectively utilized, with 18 participants listing this as their leading "Commitment to Change." Participants committed to other common practice principles identified in both the Pre-study Phase and in the workshops. These principles were contained in the bedside tools present throughout the study. The Post-study Audits served to reinforce TABLE 6 RATING OF COMMUNICATION AND CO-OPERATION Pre-study Questionnaire Post-study Questionnaire Number of Responses 26/36 Number of Responses 19/36 (72% of Study Group) (53% of Study Group) Among obstetrical units Likelihood of improved communication and co-operation in HPHP: among obstetrical units and care givers in HPHP High Low High Low Level of communication 5 4 1* 2 I 5 ~ 3 2t I Level of co-operation I Among care givers in your hospital: Level of co-operation I Strength of Leadership in obstetrics: Your hospital 5 ~ 3 2 I In HPHP I *Bold and underlined figures indicate the median response. tobstetrician respondent. JOGC DECEMBER 2003

7 these changes. The "Commitment to Change - Part 2" showed a high rate of success in their implementation. COMMUNICATION AND CO-OPERATION The study successfully focused on issues of communication and co-operation. The level of knowledge about the other partners improved through the workshops. On the Post-study Questionnaire, respondents evaluated the likelihood that the Best Practice study had improved communication and consultation in HPHP as high, with a rating of 4 out of 5. This response seems to reflect optimism and a shift from local to regional thinking. The study was the first of any co-operative effort by a department in the HPHP. A Clinical Program Planning Group has since been established for obstetrics for the HPHP, to further build on these successes. FUTURE DIRECTIONS As an extension to this study, outcome measures in HPHP could be looked at after sufficient cases have been collected. In this way, the success of the Best Practice model could be tested more fully. The SOGe, in conjunction with TKI Medcom, Inc., has developed a joint program, Managing Obstetrical Risk Efficiently (MORE OB; unpublished correspondence with SOGe, 2001). The program integrates the ALARM core content with the principles of High Reliability Organizational (HRO) structure and adult learning, with the purpose of improving patient care and reducing liability costs. Many of the principles of the Best Practice study reported here are expanded in the MORE OB program. The MORE OB program, besides utilizing trainers, professional leaders, and local workshops, uses sophisticated information systems. Self-assessment, learning, and reporting will occur on-line, allowing participants freedom and convenience. As of March 2003,21 health-care organizations, including the Regina Health District and 20 organizations in Ontario, are involved in a pilot program of MORE OB. MORE OB should prove to be a very important and useful program, providing hospitals with ongoing obstetrical quality assurance risk management, and individuals with up-to-date evidence-based information and tools to implement practice change. LIMITATIONS A weakness of this study was its limited time frame. Some of the participants, because of low volumes, felt unable to complete a Post-study Audit. The physicians who had attended fewer than 5 births (in some cases only 1 or 2 births) expressed this as a barrier and dropped out of the study, causing the participation rate among family physicians to fall from 86% to 79%. It is unknown whether the changes in practice initiated by this Best Practice study will be sustained or enlarged upon in the future. A longer study would have allowed collection of sufficient cases to analyze outcome measures such as Caesarean birth rate and neonatal or maternal morbidity. Another weakness of this study was the reducing levels of participation as the study progressed. The success of the Best Practice method depends on the completion of course materials. By the Post-study Audit, felt by the author to be the most useful aspect of the study in reinforcing change, the participation level had fallen to 67%. Strong leadership and respect among Clinical Leaders, physicians, and midwives are essential for this model to work. None of the 12 participants who failed to complete the Post-study Phase responded to the "Barriers to Completion" Questionnaire. As a result, this important information is not available. This information would have been very valuable for the successful design of future Best Practice studies. In some cases, the post-study materials, sent as a package, were misplaced over time and had to be sent again to the participants. The time commitment and effort for completion, although not onerous, may have contributed to a limited response rate. Reporting on-line might be more convenient and successful. The factors that led to only 1 obstetrician completing the Post-study Audit and questionnaire are unknown. The obstetrician who did complete these rated the study's usefulness in labour management and its likelihood to improve outcomes, communications, and co-operation as being low. It is unknown whether an obstetrician rather than a general practitioner, as Study Coordinator, would have been more effective. CONCLUSIONS This study demonstrated that a Best Practice course in the Management of Labour was well-received and an effective CME tool when undertaken by a partnership group of hospitals. The format of the course provided a basis for improving obstetrical practice and promoting the use of practice guidelines. The study in itself focused the clinicians on issues of communication and co-operation, and participants were optimistic that improvements in care were occurring as a result. ACKN~DGEMENTS This study was sponsored by the Ontario Women's Health Council and funded by the Ontario Ministry of Health and Long-Term Care. The author would like to thank Dr J. Rourke, for his review and suggestions, and Lynn Million, for the preparation of this report. REFERENCES I. Biringer A, Davies B, Nimrod C, Sternberg C,Youens W Attaining and maintaining best practices in the use of Caesarean sections.toronto: Ontario Women's Health Council;June JOGC DECEMBER 2003

8 2. Society of Obstetricians and Gynaecologists of Canada. Advances in Labour and Risk Management. 8th ed. Ottawa: SOGC; 200 I. Course outline available on-line at < courses_e.shtml>. Accessed June Glanz K. Lewis FM. Rimer BK. Health behavior and health education: theory. research. and practice. 2nd ed. San Francisco: Jossey-Bass; Davis DA.Thomson MA. Oxman AD. Haynes RB. Changing physician performance. A systematic review of the effect of continuing medical education strategies. JAm Med Assoc 1995;274(9): Iglesias S. Grzybowski S. Klein M. Gagne GP. Lalonde A. Rural obstetrics. Joint position paper on rural maternity care. Can J Rural Med 1998;(3):75-80; Can Fam Phys 1998;44:83 1-6; J Soc Gynaecol Can 1998; 72: loge Self-Assessment Test This issue of the JOGC includes a Self-Directed Learning Exercise on the JOGC Self-Assessment Test. This exercise qualifies for credits under Section 3 of the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada. Don't miss this valuable self-directed learning exercise on the loge Self-Assessment Test. 17' International CME Mell' Caribe Resort March 1-5, 2004 Punta cana, Dominican Republic (Programme offered in English! Programme offert en anglais) The Rimrock Resort Hotel April 1-3, 2004 Banff, Alberta In conjuction with ASOG (Programme offered in English! Programme offert en anglais) H6tel Falnnont Tremblant du 23 au 25 septembre 2004 Tremblant (Quebec) En collaboration avec I'AOGQ (Programme offert en franr;aisl Programme offered in French) Toronto Marriott Eaton Centre November 25-21, 2004 Toronloj Ontario In conjunction wittr OSOG (Programme offered in English! Programme offert en anglais) JOGC