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In 2017, Waterloo Wellington Local Health Integration Network (WWLHIN) submitted four sub-regional Collaborative Quality Improvement Plans (C-QIPS) to Health Quality Ontario as an innovative pilot project to advance collaborative quality improvement.

C-QIPs are multi-organizational QIPs focused on a cross-sector issue. They are coordinated at the sub-region level and drive system-level change. They represent joint commitments by staff and organizational boards involved.

Health Quality Ontario had a chance to catch up with Karen Bell Director of Acute Care at WWLHIN, and Dr. Kunuk Rhee, Chief of Staff at Cambridge Memorial Hospital and Vice President Clinical at WWLHIN, to talk about the C-QIP development process and lessons learned to date.

How did the idea of C-QIPs first come about?

Annually, WWLHIN hosts symposiums for board members, board quality chairs, and CEOs/executive directors of primary care organizations, hospitals, home and community care, mental health agencies, and long-term care homes across our four sub-regions. The goals of the symposiums are to discuss the provincial and local quality landscape, review areas for improvement, and determine ways to work together to create a high-quality, integrated health system for patients in our LHIN.

At the 2016 symposium sessions, we heard clearly that governors were ready to lead collective, system-level change, and the notion of the C-QIP was born.

To help facilitate this change, Health Quality Ontario launched a new C-QIP tool, and Waterloo Wellington was selected to be the first LHIN to use this tool to drive sub-region integration.

How did you choose the topics for your C-QIPs?

We started by reviewing our sub-region profile analysis data to determine strengths and areas for improvement. The data revealed that there were common threads that ran across our sub-regions: patient transitions, coordinating care for chronic diseases, mental health, and palliative care were quality issues that surfaced as priority topics.

At the sub-regional level, senior leaders, staff and QI leads came together to narrow the focus of the C-QIPs. We explored where there was existing momentum, energy, and passion related to the priority topics and built upon this natural emergence of leadership. The decision-making process was very iterative.

Below is a list of the C-QIPs underway per sub-region:

1. Cambridge-North Dumfries:

• Improve transitions in care for individuals with congestive heart failure with the goal of reducing readmission rates within 30 days of hospital discharge.
• Integrate mental health and addictions services into primary care with the goal of reducing emergency department return visits within 30 days.

2. Guelph-Puslinch:

• Improve transitions in care for individuals with chronic obstructive pulmonary disease with the goal of reducing readmission rates within 30 days of hospital discharge.
• Implement and evaluate a Rapid Access Clinic through the spread of the META:PHI ARTIC project for individuals with addictions with the goal of reducing inequity in care.

3. Kitchener-Waterloo-Wellesley-Wilmot-Woolwich:

• Increase access to a “palliative approach to care” in the last year of life using advance care planning.

4. Wellington:

• Improve transitions in care and care coordination from hospital to primary care for adult and older adult home care patients with the goal of reducing hospital readmission rates within 30 days.

View the WW LHIN Briefing note outlining the sub-regional C-QIPs here.

What were your first steps in getting the C-QIPs off the ground?

Our governors were ready to lead system-level change, which was an important first step. The WWLHIN then committed to seeing the C-QIP work through and getting over the initial hurdles. Working with system-level leadership and Health Quality Ontario was essential to fully engage organizations and health system providers in this work, and provide the needed assurance of process alignment with the current QIP process.

Various sub-region collaborative governance tables were formed, and workshops were held to develop and formalize the four C-QIPs. A lead health system provider in each sub-region was identified to be the main facilitator of each C-QIP.

What advice would you give to other LHINs interested in, or working on, C-QIPs?

In the first year, there were many barriers that we weren’t aware of. There were certainly growing pains. What we learned was to:

• Ensure dedicated LHIN leadership: A LHIN point person is essential to keep the momentum going and create engagement.
• Start with a “coalition of the willing” to create momentum: Have a dedicated lead organization that is passionate about the quality issue to attract other organizations. It’s important to nurture those who are willing to step forward and lead the C-QIP. Provide foundational tools and mentoring around QI leadership to build capacity especially for organizations less familiar with QI work.
• Create a level playing field: There was a large variation in the level of QI knowledge and skill across the organizations that came to the table. Some organizations have been developing their own individual QIPs for decades and some had never done any quality improvement work. It was challenging to get everyone to speak the same language. If we had to start the process over, we would have spent even more time creating more foundational QI knowledge across organizations.
• Be prepared for delays in board sign-off on the C-QIPs: We decided to finalize the C-QIPs as early as possible to allow time for boards to review and sign off across the organizations involved. Boards have their own meeting schedules that we needed to adapt to, so we wove the C-QIP sign-off into their existing processes.
• Address resistance: Working in a different way is always challenging and can create some anxiety for organizations. We stressed the impact that the C-QIPs could have on system-level change and the importance of publicly signing off on the C-QIPs to signal a declaration and commitment to the community.
• Speak the language of front-line staff: When engaging front-line staff in this C-QIP work, we didn’t call it “C-QIP” or “QI”. We said we were trying to make it easier for them to do their job and improve the patient experience. Then we went back to these staff members to demonstrate the improvements that were made to further increase their buy-in.

Although we faced many challenges, the groundwork has been worth it. At the time it seemed that there were monumental hurdles to overcome. Now it’s second nature. It is not the default position to be collaborative, but once you do, you’ll never look back.

What are your next steps?

The next few years of sub-regional work will be to test the C-QIPs as a way for health service providers to work together. The WWLHIN and Health Quality Ontario will continue to pilot year two of the C-QIP approach.

You may also be interested in:

How do you create a C-QIP? Spotlight on Cambridge-North Dumfries Sub-Region of Waterloo Wellington LHIN