The North Perth FHT, North Huron FHT and Listowel Wingham
Hospitals Alliance (LWHA) have successfully strengthened their partnership
to reduce 30-day hospital readmission rates for COPD in their LHIN sub-region
from 9.6% to 4.6% over a two year period.
Health Quality Ontario had a chance to catch up with Lindsay McGee, Quality Manager and Quality Improvement Decision Support Specialist at North
Huron and North Perth FHTs to find out how they achieved this success.
How did this
partnership first come about?
For some time, COPD was identified as a priority area by
both FHTs and our two hospitals in the Hospitals Alliance. Initial work was being done within the walls
of each organization, but there was limited success and not much sharing occurring.
It was also clear that our respective
organizations were serving the same population in our sub-region, so it made
sense to work together to provide more efficient care.
We decided to strike a partnership with representation from
- James Brown, Clinical Pharmacist at North Huron
- Joanne Fox, Clinical Pharmacist at North Perth FHT
- Christine Reyes, Registered Nurse, Coordinator
of Professional Practice at LWHA
- Heidi Dupuis, Decision Support at LWHA
- Ainsley Morrison, Quality and Patient Experience
Coordinator at LWHA
- Myself, Lindsay McGee, Quality Manager and Quality
Improvement Decision Support Specialist at North Huron and North Perth FHTs
Key enablers to this relationship included a joint position
of Quality Manager at both the Family Health Teams and the Hospitals Alliance.
How do you work
One of the most important enablers was a strong shared
vision within leadership and governance across the two FHTs and Hospitals
Alliance. There is hospital leadership at
the FHTs’ Board of Directors, and the FHTs and hospitals share a Business
Manager and Quality Manager.
Another key enabler is a shared I.T. Governance Committee,
and data sharing agreement between all parties.
Both FHTs have the same electronic medical record (EMR), which is now
available in the hospital. The hospital
EMR is available at the FHTs. This
provides access to more reliable data.
For example, emergency
department staff can look up medications and medical history in the primary
care EMR. They can look to see if a patient is in a Lung Health program and can
ask them if they are using their action plan. The hospital pharmacist can
access the primary care EMR to help them complete medication
Every three years, we host a joint strategic planning meeting
to decide on our goals and objectives. This culminates in a joint Quality
Improvement Plan that we work on for the following three years.
What improvements did
you make as a team?
We focused on how we could improve the transition of
patients from hospital to home and implemented the following strategies:
1. Implementation of a COPD order set in the emergency
department and a COPD Clinical Pathway for inpatient units across our Hospitals
An order set focusing on COPD allowed physicians to utilize
the same treatment methods amongst providers, no matter the severity of the diagnosis.
clinical pathway was implemented on the inpatient units for staff to follow
treatment plans such as incentive spirometry over the course of the hospital stay.
patient pathway booklet and action plan was created for plan of care awareness throughout their
2. Implementing staff education in hospital and
Hospital staff were educated on the use of the COPD Clinical
Pathway, which includes referral to a Lung Health Program available through the
FHTs as appropriate. Previous to our partnership, hospital staff were not
familiar with the programs available through the Family Health Teams. There is
such a benefit to the patients to have a follow up visit with their primary
care provider to assess their lung status and complete a medication
reconciliation in the community. Now hospital staff are able to send clients
home with an appointment already scheduled within 7 days, which is very
important to transition them to community care and avoid readmissions.
3. Standardizing the process for booking
follow-up appointments for all COPD discharges from the hospital to the Family
Health Teams within 7 days of discharge
A ward clerk books a follow up appointment with a
practitioner upon discharge from the hospital.
What were your
Our results showed a decrease in COPD patients readmitted to
Listowel Wingham Hospitals Alliance (LWHA) from 9.6% to 4.6% despite an
ever-increasing population of patients being discharged with COPD.
In addition to our “big dot” measure, we track the following
- Percent of COPD patients who had a follow-up appointment
booked on discharge
- Percent of COPD patients who had emergency
department order set used on admission
- Percent of COPD patients who had clinical
pathway used for inpatient stay
These process measures were collected for short period of
time to ensure processes were being followed and now we monitor them
periodically to ensure sustainability.
What are your next
One of the best outcomes of this initiative are the strong
relationships that have been built that can be leveraged for other priority
issues. The FHTs and the Hospitals Alliance
have a much clearer understanding of each other’s role in the care of patients
throughout the system.
We will be building on this shared success and work on
opioid prescribing, mental health and coordinated care planning.
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