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Word first: Sunnybrook unlocks bloodbrain barrier

A good year for health care infastructure



Canada's Health Care Newspaper DEC. 2015 | VOLUME 28 ISSUE 12 |

INSIDE From the CEO’s Desk ........................... 8

Overview of advancements and trends in healthcare in 2015 and a look ahead at trends and advancements in health care for 2016. An examination of how hospitals are improving the quality of services through accreditation. An examination of safe and effective use of medications in hospitals and clinical pharmacology.

Safe Medication ................................. 17 Nursing Pulse .....................................26 Evidence Matters ............................... 27 Legal Update ......................................28


opioid use By Dr. David Juurlink

Story on page 12





Bonny Hall being prepped for the focused ultrasound procedure. A head frame was screwed to her skull and she laid down on the MRI bed where the head frame was connected to a “helmet” that is part of Insightec’s Exablate Neuro System.

A world first: Sunnybrook unlocks barrier and possibly new ways of treating brain disease By Nadia Norcia Radovini and Monica Matys


or eight years, Bonny Hall managed her brain tumour with medication. But earlier this year, she was given diffi-

cult news. “[My tumour] was starting to grow and I would have to see somebody…like Dr. Mainprize,” says Bonny. Dr. Todd Mainprize is a neuro surgeon at Sunnybrook. He is also the lead investigator in a groundbreaking clinical trial: for the first time in the world, this Sunnybrook team penetrated the blood-brain barrier non-invasively in a human – in Bonny. The blood-brain barrier is described as a plastic wrap-like coating around the small blood vessels in the brain that normally restricts the passage of substances from the bloodstream into the brain, protecting it from toxic chemicals. Unlike other areas of the body, this plastic wrap doesn’t allow most medications to get through, which has implications for many conditions, including brain cancer, Parkinson’s and Alzheimer’s disease. “Some of the most exciting and novel therapeutics for the treatment of malignant brain tumours are not able to reach the tumour cells because of the blood

Sunnybrook scientists made history as they used focused ultrasound to noninvasively breach the blood-brain barrier in an effort to more effectively deliver chemotherapy into the brain tumour of a patient. brain barrier,” says Dr. Mainprize, also an assistant professor in the Division of Neurosurgery at University of Toronto. “Our technique is to essentially tear holes in the plastic wrap and allow the various chemicals we want delivered to the brain, to get into the brain.”

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Bonny was given chemotherapy and then later, an injection of microbubbles, or microscopic bits of air. Both circulate in her bloodstream. She was fitted with a specialized helmet-like device – co-developed based on Sunnybrook research – and placed inside an MRI, which helped guide low-intensity ultrasound waves (or sonications) to precise areas in her brain. This causes the microbubbles to shake and temporarily rip holes in the blood-brain barrier, allowing medication to seep into the tumour. “The trial has gone exactly the way we hoped,” says Dr. Mainprize. During the procedure, nine dots on the brain scan lit up, indicating the opening of the blood-brain barrier. “We are encouraged that we were able to temporarily open this barrier in a patient to deliver chemotherapy directly to the brain tumour. This technique will open up new opportunities to deliver potentially much more effective treatments to the targeted areas.” Dr. Kullervo Hynynen, Director of Physical Sciences at Sunnybrook Research Institute, worked with industry partner Insightec for almost two decades to develop the technology and bring it to a clinic-ready

state. “The success of this case is gratifying,” he says. “My hope now is that many patients will eventually benefit from it.” Bonny had part of the tumour and surrounding tissues removed in surgery the next day. It was sent to pathology for analysis to determine just how much medication got through. Since the injected chemotherapy is taken out with the removal of the brain tumour, Bonny and the other research participants in this trial will not benefit from this particular focused ultrasound procedure. “Research participants, like Bonny, are committing a truly selfless act to help research along so it may be able to help other patients in the future,” says Dr. Mainprize. “Thanks to Bonny and all other participants, this breakthrough opens up potential for delivering drug therapies to parts of the brain that were previously impenetrable because of the blood-brain barrier.” Bonny said she was both nervous and excited to be the first. “If I can help in any way, it’s going to be able to look after things like epilepsy, Alzheimer’s and a lot of other diseases. This isn’t just about a brain tumour.” “We are very lucky at Sunnybrook to have a large interdisciplinary group of physicists, radiologists, neurosurgeons and oncologists that can work together and push this trial forward. We’re very honoured to be the first centre that’s able to do this,” says Dr. Mainprize. The trial will include six to 10 more patients over the coming months – all to make sure opening the blood-brain barrier is safe to penetrate in humans. These research participants are those who are already scheduled for traditional neurosurgery to remove parts of their brain tumour. Enrolment is currently limited to Canadian residents only, due to being an inpatient surgical procedure. For more information on this research H procedure, visit ■ Nadia Norcia Radovini and Monica Matys work in communications at Sunnybrook Health Sciences Centre.

In Brief

Ontario sets organ and tissue donor registration record

Disparities in care point to need for complex cancer surgical centres There is “tremendous” variance in inhospital mortality, resection rates and length of stay outcomes in high-risk cancer surgical care across Canada, says a new study commissioned by the Canadian Partnership Against Cancer. “If our goal is to improve cancer care and outcomes, the evidence tells us that patients requiring complex surgeries can benefit from having their procedure performed at a regional centre of excellence, where these types of surgery would be performed more often,” says Dr. Christian Finley, a thoracic surgeon at St. Joseph’s Health Centre in Hamilton and lead author of the Approaches to High-Risk, Resource Intensive Cancer Surgical Care in Canada paper. The study found notable disparities between provinces in patterns of practice and patient outcomes for surgical cancer care. In evaluating the outcome of surgical procedures for esophageal, pancreatic, liver, lung and ovarian cancers, it found

up to three to four times difference in mortality rates across provinces. Surgical resection seeks to completely remove a tumour and in many cases is the only or best chance of cure in these cancers. The paper found the likelihood of receiving a potentially curative operation in a province with high resection rates can be double that of provinces with lower rates. It noted wide differences in the length of hospital stays, a sign of system efficiency and differing hospitalization policies. Regionalization – where high risk, high resource cancer surgery cases are grouped into specific centres – would not only provide more opportunities to build skills in performing complicated cancer surgeries, it would also encourage the development of high-functioning, specialized teams of nurses, anesthesiologists, radiologists and pathologists. At present, there is minimal regulation as to which procedures surgeons or hospitals can or should perform within their specialty area, or how fre-

The Canadian Foundation for Healthcare Improvement (CFHI) recently released a study revealing inconsistencies in visiting policies at hospitals – frequently limiting visiting by family members and loved ones during morning and evening hours. A baseline study of 114 acute care hospitals across Canada reveals only 30 of the hospitals received top marks for having visiting policies that promote family presence and patient-centred care. “Isolating patients at their most vulnerable times from the people who know them best can place them at risk for adverse events, emotional harm and inconsistent care,” says Maureen O’Neil, President, Canadian Foundation of Healthcare Improvement. Evidence shows a clear benefit to adopting a patient and family centred approach to visiting hours, including: fewer medication errors and falls; improved patient outcomes and experience of care; better informed medical assessments and care planning; and reduced lengths of stay, readmissions and emergency department visits. To promote more patient- and family-centred care at Canadian hospitals, CFHI has launched a national campaign called Better Together: Partnering with Families encouraging hospitals to review their policies with a view to adopting family presence policies. These policies/ guidelines enable patients to designate family members and loved ones who can stay by their side 24 hours a day, seven days a week.

“Having my family with me while I was in hospital not only made the experience more tolerable, it was also an important part of easing my transition back home. They had been with me every step of the way which meant they understood how to support me when I left the hospital,” says Emily Nicholas Angl, Patient Advisor, Patients Canada. “We can have the best policies in place, but to really be people-centred we have to allow for responsiveness to individual needs.” Leading hospitals across Canada that have already adopted family presence policies in place of more traditional visiting hours include: Kingston General Hospital, Alberta Health Services South Campus, and Providence Health Care in Vancouver, British Columbia. To determine how open visiting policies in Canada are at the present time, CFHI earlier this year conducted a baseline study of 114 acute care hospitals, reviewing both the hospital’s posted visiting policies and how well they were communicated through the hospital’s website. Calls were then placed to the hospital’s switchboard operator to confirm the posted policies – the same approach a patients’ family might use. This report sets in motion the collaboration needed to highlight the importance of patient-family centered care. To reach this goal, the study includes the following recommendations to hospitals: •View families and loved ones as partners in care and engage them in plan-

More than 89,000 Ontarians registered their consent for organ and tissue donation between July 1, 2015 and September 30, 2015, setting a new record for registrations in one quarter. Since the province adopted an affirmative registry in 2008, Trillium Gift of Life Network has seen a significant increase to the registration rate, growing from 16 per cent to 28 per cent today. Currently, 3.34 million individuals in Ontario are registered organ and tissue donors. Every day 1,600 people in this province are waiting for a lifesaving call, making registering consent vital. When TGLN coordinators share with a family that their loved one wished to be a donor and had registered consent, families in the majority of cases fulfill their loved one’s wish to give the gift of life. Between July 1, 2015 and September 30, 2015 there were 255 organ transplants in Ontario. Registration rates vary widely across the province. Nearly 1,000 individuals register each day and over 90 per cent of those come through a ServiceOntario office, either in-person when renewing a driver’s license or health card, or by mail. Registration data is available for 179 communities across the province at H scoreboard. ■

quently they need to perform these procedures to ensure their surgical skills remain up-to-date. “Restructuring medical care to achieve higher volumes has shown to be beneficial in other clinical scenarios such as organ transplantation and pediatric cardiac care,” says Dr. Geoff Porter, Expert Lead in Clinical Care at the Partnership. “This paper suggests gains may be realized by considering how high risk cancer surgery is delivered in Canada. It’s imperative that we delve deeper, understand the drivers and discuss the idea of regionalization for these high-risk, high-resource surgeries.” The study’s authors recommend the development and implementation of disease-site specific national standards of surgical cancer care; better alignment of cancer surgery within provincial cancer delivery systems; and ongoing collection of cancer surgery data to help identify benchmarks and improve surgical H quality. ■

Should Canadian hospitals have 24-hour visiting policies?


Coming next month

ning and decision-making based on patient needs and preferences. • Creating a more welcoming environment for loved ones is a step that hospitals can take to make the care they provide more patient and family centred. • Hospitals, regional health authorities, long-term care facilities and facilities across the continuum of care are encouraged to sign the Better Together pledge at: BetterTogether • CFHI is providing resources to help hospitals make this change by developing and implementing family presH ence policies at their institution. ■

The first of a three part series on Hospital-Physician Relationships: Over the past year the Ontario Hospital Association (OHA) has been engaged in work to strengthen hospital-physician relations as these relationships are critical to the delivery of quality patient care, quality improvement and system transformation. This series will highlight the consistent themes that influence the working relationships between physicians and hospitals and highlight Ontariobased research to better appreciate how to further strengthen these relationships.

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Guest Editorial

UPCOMING DEADLINES JANUARY 2016 ISSUE EDITORIAL DECEMBER 4 ADVERTISING: DISPLAY DECEMBER 11 CAREER DECEMBER 15 MONTHLY FOCUS: Professional Development/ Continuing Medical Education (CME)/ Human Resources: Continuing Medical Education (CME) for health care professionals. Human resource programs implemented to manage stress in the workplace and attract and retain health care staff. Health and safety issues for health care professionals. Quality work environment initiatives and outcomes. + PROFESSIONAL DEVELOPMENT SUPPLEMENT

FEBRUARY 2016 ISSUE EDITORIAL JANUARY 8 ADVERTISING: DISPLAY JANUARY 22 CAREER JANUARY 26 MONTHLY FOCUS: Facilities Management and Design/ Health Technology/Greening Healthcare/Infection Control:

Innovative and efficient health care design, the greening of healthcare and facilities management. An update on the impact of information technology on health care delivery. Advancements in infection control. + INFECTION CONTROL SUPPLEMENT


Hospital News is provided at no cost in hospitals. When you visit our advertisers, please mention you saw their ads in Hospital News.


LEAVE A GIFT IN YOUR WILL TO MSF Help us provide medical assistance wherever the need is greatest by remembering Médecins Sans Frontières/ Doctors Without Borders with a gift in your will. For information, contact Emily Harris: 1-800-982-7903 or

Listening to patient complaints can

improve healthcare By Dr. Joshua Tepper am leaving you,” she said. “I’m finding a new doctor.” I remember feeling stunned. My patient looked at me and continued, “You aren’t here often enough.” Over the next few minutes, she explained how difficult she felt it was to get an appointment with me. She said she worried about whether she would be able to regularly access my care as some of her chronic conditions worsened. I did the only thing I could do. Reassured her that her complaint was understandable, and then suggested the names of colleagues I thought would be available to take on her care. When she left my clinic, I felt hurt and confused. It was the first time in 15 years of practice I had a patient ask to part ways with me. I’ve prided myself on being a good clinician – and for me, that’s meant making sure my I focused on each patient’s individual needs and allowed for the time they needed during each appointment. Over the next few days, I realized my patient was right. I wasn’t in full-time practice; I had also recently taken on a large number of patients with complex conditions. I needed to reflect on doing things better. Another realization was recognizing that this patient may not be an outlier in my practice. There were probably others with similar sentiments; some might leave without telling me, some might stay and never say a thing. I grew to appreciate my patient’s frankness. Just as it was hard for me to hear her complaint, I imagined it must have been hard for her to raise it directly with me too. I suspect that many pa-



Senior Communications Officer The Scarborough Hospital,

Barb Mildon,

RN, PHD, CHE , CCHN(C) VP Professional Practice & Research & CNE, Ontario Shores Centre for Mental Health Sciences

610 Applewood Crescent, Suite 401 Vaughan Ontario L4K 0E3 TEL. 905.532.2600|FAX 1.888.546.6189









tients with concerns about their care might not always know where to turn. Complaints should not be hard for patients to make or for providers to receive. One of the best ways to ensure complaints serve their purpose – that is to say, point out important issues so we can improve care – is to create systems that can properly manage them. That way everyone feels heard; no one slips through the cracks.

The new regulation will better inform patients about how to make a complaint, and it will ensure designated patient relations representatives are in place in all hospitals across Ontario. One way in which the health system is improving its complaints management is through Ontario’s recently enacted Regulation 188/15. The regulation came into effect on September 1 to aid in spreading and strengthening the patient complaints processes already in place in many hospitals. The regulation builds on efforts that began in April 2014, when the Ministry of Health and Long-Term Care proposed amendments to bolster patient relations and patient engagement efforts under the Excellent Care for All Act (2010). The new regulation will better inform patients about how to make a

Helen Reilly,

Publicist Health-Care Communications

Jane Adams,

President Brainstorm Communications & Creations




Dr. Joshua Tepper is a family physician and the president and CEO of Health Quality Ontario, the provincial advisor on health care quality. He is an associate professor at the University of Toronto.

Bobbi Greenberg,

Health care communications

Sarah Quadri Magnotta, Health care communications

Dr. Cory Ross,

B.A., MS.C., DC, CSM (OXON), MBA, CHE Dean, Health Sciences and Community Services, George Brown College, Toronto, ON

Akilah Dressekie,

Ontario Hospital Association

David Brazeau

Director, Public Affairs, Community Relations and Telecommunications Rouge Valley Health System

complaint, and it will ensure designated patient relations representatives are in place in all hospitals across Ontario. New standards for storing patient feedback and data will be introduced across all hospitals. Collecting information like this will improve the way we deliver care because we will have a way to measure what’s really happening. This regulation is supported by organizations like Health Quality Ontario, where I serve as president and CEO, and the Ontario Hospital Association, through the creation of patient relations guides and toolkits. With the informed support of everyone, accountability for patient experiences will become more intrinsic to the system at large. My patient’s complaint inspired me to look at my own practice. I am starting to restructure my time in clinic over the course of a week, using email and phone calls more frequently, and better integrating the other highly skilled members of the team. I am also thinking about how patients could have the ways and means to share concerns in a manner that feels safe for them and helpful for me. While the new regulation applies to hospitals, I think it can serve as good motivation for all parts of the health care system. The more we listen to patients – complaints, criticism, concerns and compliments – the more we demonstrate that our health system is not H just for them but shaped by them. ■


Hospital News is published for hospital health-care professionals, patients, visitors and students. It is available free of charge from distribution racks in hospitals in Ontario. Bulk subscriptions are available for hospitals outside Ontario. The statements, opinions and viewpoints made or expressed by the writers do not necessarily represent the opinions and views of Hospital News, or the publishers. Hospital News and Members of the Advisory Board assume no responsibility or liability for claims, statements, opinions or views, written or reported by its contributing writers, including product or service information that is advertised. Changes of address, notices, subscriptions orders and undeliverable address notifications. Subscription rate in Canada for single copies is $29.40 per year. Send enquiries to: Canadian Publications mail sales product agreement number 40065412.




“Our partnership with the Public Services Health & Safety Association allows for JHSC training that is focused on the health & safety issues that our hospitals see. It is relevant training and PSHSA knows how to connect with our JHSC members to keep them engaged.” Steve Jamieson Safety Manager, Health, Safety and Wellness Hamilton Health Sciences

PSHSA sat down with Steve to discuss what makes a good JHSC and how PSHSA has built a successful partnership with Hamilton Health Sciences:

Q: How long have you worked with the Public Services Health and Safety Association as your Health and Safety training partner? How is it a good fit?

A: Hamilton Health Sciences (HHS) originally worked with OSACH in the early 2000s and have enlisted JHSC Certification training services of PSHSA since 2012. The service that PSHSA provides is excellent. A highly valued characteristic of the training is that it is delivered from PSHSA staff who have relevant health care experience and are able to connect with our members. We continue to hear from our members how in tune their staff are to our environment and are able to share relevant examples. It creates a great learning atmosphere. Q: What is important for a good JHSC training program? How does PSHSA deliver?

A: PSHSA’s certification program provides all JHSC members with a clear understanding of the OHSA, including how they fit in supporting the organization’s health and safety program and ways they can make an impact in supporting workers’ concerns. The different methods used to deliver the training keeps the members interested and engaged.

Q: What are emerging health and safety issues that the JHSC are faced with and how does PSHSA assist?

A: As PSHSA is funded by the Ministry of Labour, they are consistently involved in discussions related to emerging health & safety issues and implementation plans of new legislation. Within the training sessions offered to us, PSHSA staff provide opportunities for us to discuss and better understand new issues that workers are raising to our Committee members. Through these discussions, our members gain tools to better assist them in identifying health and safety issues and methods to support our workers.

Q: What sets PSHSA apart from other training vendors? How can we do better? A: PSHSA’s knowledge of health care settings and focused training geared to our challenges is the difference for us. They tailor the training to include our practices and processes which greatly helps everyone understand their role. Our members immediately are engaged in the training offered as PSHSA staff have practical experience within our settings which provides insight to the challenges our hospitals see.

The JHSC Standard is Changing. Learn More:

Bundle Cert 1 & 2 and save. Call 1-877-250-7444 to register and talk to a Regional Consultant.





Medication safety program wins award By Riannon John s our population ages, more people are managing multiple chronic and complex conditions requiring many different types of medication. The desire to empower patients to partner with their primary health care providers to promote effective medication use is at the heart of a new and innovative medication safety program at Mount Sinai Hospital, part of Sinai Health System. The Mount Sinai Academic Family Health Team developed the Brown-Bag Medication Check-Up Program, which was recently recognized by the Association of Family Health Teams of Ontario with a Bright Lights Award for transforming patients’ and caregivers’ experiences and health. Family Health Team patients with conditions such as diabetes, angina, heart failure, hypertension, asthma or COPD, may self-refer or be referred by any family medicine team member to the clinic pharmacist for a comprehensive Brown-Bag Medication Check-Up. Patients are provided with a brown paper bag to gather all of their current medications and over-the-counter products together in, before coming in for their next appointment. The clinic pharmacist, Suzanne Singh, works with patients and their providers to go through


each medication with the patients, identifying and explaining any potential problems, such as mediations that have adverse effects or interact negatively with each other, dangerous or unpleasant side effects, and incorrect dosages. Through patient education and medication safety recommendations, this ensures safe and effective medication management.

The desire to empower patients to partner with their primary health care providers to promote effective medication use is at the heart of a new and innovative medication safety program at Mount Sinai Hospital. The clinic uses a creative patient-engagement strategy, including video promotion in the clinic’s waiting room and Facebook page, with brown bag displays in clinic exam rooms so patients may easily pick up a brown bag containing information about the initiative and instructions on gathering medications.

The Brown-Bag Medication Check-Up Program at Mount Sinai Hospital recently won an award for transforming patients’ and caregivers’ experiences and health. Feedback from patients has been positive. “Patients seem to appreciate the opportunity to have a personalized medication review where no medication-related question is off-limits,” Ms. Singh notes. She also noted that the program’s inter-professional approach is critical to its success. “Our team includes a diverse complement of family doctors, family medicine residents, nurses, nurse practitioners, social workers, dietitians, administrative staff and me. The program draws on the expertise of all team members to help promote a culture of medication safety.” “I’m very proud of our Family Health Team for taking a leadership role in addressing the important issue of medication safety,” says Dr. David Tannenbaum, Family Physician-in-Chief at Mount Sinai Hospital, part of Sinai Health System.

“This award recognizes the importance of simple and effective team-based initiatives that are anchored in primary care where we can engage our patients with the aim of improving their health outcomes. The Brown-Bag Medication Check-Up Program is a great example of how Sinai Health System is championing improved care for patients with chronic conditions through unique, collaborative partnerships between care providers and patients to optimize medication management.” The Family Health Team is committed to the ongoing evaluation and dissemination of the Brown-Bag Medication CheckUp Program, which is designed to be shared with other family physicians, interH professional teams, and patients. ■ Riannon John works in communications at Mount Sinai Hospital.

OPSEU hospital workers across Ontario wish your family a healthy and happy holiday season! HOSPITAL NEWS DECEMBER 2015







IMPROVESAND GETS KATE COORDINATIONTO HER FAMILY OF CAREREUNION IN WINNIPEG. Patients. Families. Healthcare Providers. Family presence improves patient experience and outcomes.

Take the pledge at CFHI is a not-for-proямБt organization funded by the Government of Canada.



From the CEO's Desk

Let’s strengthen innovation beyond the acute care hospital By Dr. William Reichman or those of us in non-acute, community-based health care organizations and specifically, the senior congregate living and home care industries, it should come as no surprise that we are in the midst of a revolution in how we will support the unprecedented aging of our communities. Technology advances, changing consumer expectations, rationing of financial resources for health care delivery, and rapidly changing demographics have all combined to drive us to change and improve the way we approach the care and support of older adults. Today’s imperative is to substantially strengthen innovation beyond the acute care hospital setting to optimize wellness and to identify novel approaches to chronic disease management that reduce the need for avoidable, episodic high intensity care. Following our acute care colleagues that have led the way, the community-based senior care sector is beginning to embrace the potential we collectively possess to adapt and to lead the changes we know are required across health delivery systems. What has traditionally been a comparatively conservative risk-averse group is now, for the first time, driving the innovations that are transforming the very way we care for seniors in our communities.

The Canadian Centre for Aging and Brain Health Innovation (CC-ABHI) at Baycrest Health Sciences is an example of how our community-based sector is working to transform seniors’ healthcare.



We are in the midst of a revolution in how we will support the unprecedented aging of our communities.

Dr. William Reichman In the past, we relied heavily on academia and industry to develop innovations that could be imported into the seniors’ health care space. The problem is, many of the solutions they developed were not tested and validated in real-world settings where seniors actually live and access care, or they failed to meet the priority needs of their intended audience. Too often, innovation in this sector has been pushed into the hands of end users, when in reality, what was needed was more pulling of ideas.

Announced last May – with $123.5 million in support from the Government of Canada, the Government of Ontario, and 40 health care, academic and industry partners – CC-ABHI’s mandate is to accelerate the development and adoption of innovations that can improve the experience of aging for millions of seniors, here in Canada and around the world. Though still in its infancy, CC-ABHI will serve as a “test kitchen” of ideas to find ways to help seniors live safely in the setting of their choice for as long as possible – potentially even delaying or avoiding the need for hospitalization or a move to long-term care. CC-ABHI’s North American wide community-based health and senior care provider organizations will collaboratively function as ideal development and testing labs for products, services and practices that will enhance the

physical, cognitive and mental well-being of older adults. Through CC-ABHI, frontline health providers may have access to funding, research, emerging technologies, project management and marketing support that could turn brilliant front-line ideas into real-world solutions – solutions that have been clinically and scientifically tested and validated to ensure they deliver on their promise. And the business reality is that health care organizations are reluctant to procure products or services that lack real-world evidence of cost-effectiveness. CC-ABHI will build that evidence, and help member organizations become early adopters of the most successful ideas in the innovation pipeline, creating continent-wide distribution channels that can reach an even greater critical mass of seniors. The unprecedented investment by the provincial and federal governments demonstrates the thirst for – and the value of – nnovations in the health and aging space. Now, for the first time, the community-based senior care industry is being embraced, not just as an end user of solutions, but as an originator and developer of the next generation of health products, servicH es and practices for an aging population. ■ Dr. William Reichman is President and Chief Executive Officer of Baycrest Health Science, and Professor of Psychiatry at the University of Toronto.




Accreditation enhances care By Preet Grewal

fter a rigorous review, BC Emergency Health Services (BCEHS) has earned accreditation, as the organization continues to further align its patient-first approach with other health care services in British Columbia. BC Emergency Health Services (BCEHS) is responsible for the delivery and governance of pre-hospital emergency medical care and inter-facility patient transfer services through the BC Ambulance Service and the BC Patient Transfer Network. BCEHS successfully fulfilled the requirements of Accreditation Canada’s Qmentum Program which focuses on quality and safety throughout all aspects of a health care organization’s services. “Becoming accredited is an important step towards seamless integration within the health care system,” says BCEHS Executive Vice-President Linda Lupini. “The accreditation journey has helped all employees understand their role in supporting and providing high-quality patient care.” In October, the Accreditation Canada survey team assessed BCEHS’ leadership, clinical programs and services against national standards and required organizational practices (ROPs). The survey team spent five days visiting 59 BCEHS sites across the province – from remote ambulance stations and regional headquarters, to crews handing over care at hospitals and everything in between. The Accreditation Canada final report indicates that BCEHS met 88 per cent of all criteria as well the requirements for 15 of the 16 ROPs.


Successful community paramedicine programs in Alberta and Saskatchewan have resulted in fewer medically unnecessary 911 calls and improved patient satisfaction. “We know there is still more we can do to improve the care we provide,” Lupini says. “Moving forward, we’ll use accreditation as our blueprint for enhancing the services we provide for both our patients and employees.” Vanderhoof Unit Chief Colin Clyne, who has worked for BCEHS for 32 years, agrees. He believes the focused direction provided by accreditation has brought positive changes throughout the organization. “Accreditation is a tool that helps us all do our jobs better,” Clyne says. “Best practices are presented within the framework of why and how they can help us improve the patient care we provide. They are goals that we are striving to meet at every opportunity.” BCEHS is a vast and complex organization that not only provides pre-hospital care to diverse populations in remote, rural and urban communities throughout the province; but also coordinates the interfacility transport of patients with receiving and sending facilities. Approximately every minute of every day a paramedic

crew is dispatched to an incident. Clinical nurses and dispatchers coordinate over 260 patient transfers daily. Critical care paramedics respond to over 6,700 events via air ambulances annually. “BCEHS has a large mandate and there are a variety of nuances and intricacies within every facet of the care we provide,” Clyne says. “What the accreditation process does is it focuses the organization on what unites us all, patient care and safety.” The accreditation team noted excellence in care at both the practitioner and patient level as an organizational strength. Paramedics and dispatchers are passionate about patient care and welcome ongoing professional development and technological advancements to support improving services. “The unwavering personal commitment I see in so many of our staff members who dedicate themselves to helping others is our greatest resource, “Lupini says. “Now our job is to develop ways to support their work and make their jobs easier.” One way BCEHS is supporting its frontline staff is through the implementation of innovative care models such as community paramedicine, an initiative that will employ paramedics to provide health care services, within their scope of practice, in non-urgent settings. Successful community paramedicine programs in Alberta and Saskatchewan have resulted in fewer medically unnecessary 911 calls and improved patient satisfaction. The BC Government has committed to creating at least 80 new full-time-equivalent positions at BCEHS to support community paramedicine programs throughout the province over the next four years. In addition, BCEHS is investigating opportunities to shift the focus of pre-hospital care from transport to more patientcentred and pre-emptive care in order to help alleviate the demands on paramedics and hospital emergency departments. Accreditation is an ongoing commitment to continuous quality improvement

through the pursuit of best practices. Accreditation Canada supports this commitment through an ongoing survey process to ensure consistent national standard compliance.

For more information on BC Emergency H Health Services, please visit:■ Preet Grewal is a Communications Officer atBC Emergency Health Services.

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10 Focus


Gary Ryan, Chief Innovation Officer and Vice President, Partnerships and Business Development, Southlake Regional Health Centre speaks to a crowd at CreateIT Now’s Grand Opening Celebration.

Opening the doors to innovation By Kathryn Perrier ctober 23 marked a major milestone for our Strategic Plan with the grand opening of our centre of innovation, CreateIT Now at Southlake. More than 100 eager and engaged community partners and entrepreneurs joined us to celebrate the opening. Channeling their excitement for the future of innovation here in Newmarket, Gary Ryan, Chief Innovation Officer, proclaimed that: “Today is all about what happens when you get a bunch of creative people together whose desire is, at a minimum, to figure out how to change the Canadian health care paradigm.” As part of our Strategic Direction to Seek and Share Better Solutions, Southlake’s Research and Innovation team launched CreateIT Now in partnership with the Town of Newmarket, ventureLAB, Seneca College, York University, and York Region, to foster innovation in the health care sector and serve as a catalyst for a health tech business cluster in Newmarket.


Located in the Southlake Village and structured as a health care focused business incubator, CreateIT Now offers the business advice one would expect from such an organization, and can now offer access to working space, meeting rooms, the ultra-high speed Ontario Research and Innovation Optical Network (ORION), and, most importantly, access to the Hospital – something you don’t often find in business incubators, but is crucial to the success of health care startups. In Ontario, up to 90 per cent of health care startups fail in large part because they don’t have access to the health care system while developing their product. “With no early adopters, no first sales, and no foothold in Ontario’s complex procurement system, too often these companies don’t get their products to market,” says Pat Clifford, Director of Research and Innovation. This sobering reality spurred Southlake to focus their innovation efforts on helping entrepreneurs get into the market. “We were concerned that devices and technologies that could have a real ben-

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efit for our patients might be lost if these businesses don’t succeed,” says Dr. Dave Williams, President and CEO. “To counter this, we focused on developing a business incubator and launched CreateIT Now at Southlake.” The incubator is working with a range of entrepreneurs, eager to evaluate the effectiveness of their ideas and see if their product can solve some of the challenges of our complex health care system. For example: • SterileCare is a fresh startup based in Newmarket developing a better way to avoid infections. • Inideo, founded by Southlake interventional cardiologist Dr. Sylvan Plante, offers a cardiac specific electronic medical record. • Kronos is a Winnipeg-based social networking company bringing its technology to link health care providers and improve clinical communication in the hospital environment. To begin laying an innovation pipeline, three years ago, Southlake and ventureLAB collaborated to develop the Healthcare Ecosphere – a Dragons’-Denstyle innovation pipeline that has startups pitch their products to Hospital and ventureLAB staff as a way to quickly connect with entrepreneurs. In the first two years Southlake chose to work with 14 companies through the ecosphere process. “The ecosphere showed us there are many promising companies using technology in ways that could make a difference for our patients, but they’re challenged to break into the health care sector,” says Ryan, “so it also proved there is a demand for a community-hospital-based incubator.” The incubator has found more demand than initially expected, having now worked with more than 40 client companies whose devices and technologies are at every stage of development – most coming through word-of-mouth referrals. While it is attractive to innovators to get into a health care setting, the hospital is also benefiting from the ecosphere as a way to procure innovation. “It is working both ways,” says Pat Clifford, Director Research and Innovation. “We open our doors through the ecosphere to companies with interesting technologies and we also look to companies through an innovative procurement process that can solve problems for us. In so doing, they prove not only to us, but the Ontario and Canadian

acute care sector, the solution works.” Opening our doors to startups isn’t just benefiting the health care sector though. Barriers to start ups not only frustrate entrepreneurs, but also contribute to a national innovation gap. While Canada ranks third in per capita spending on research amongst Organisation for Economic Co-operation and Development (OECD) states, the country ranks 13th when it comes to commercializing that research.

In Ontario, up to 90 per cent of health care startups fail in large part because they don’t have access to the health care system while developing their product. “It’s a big gap, but we see CreateIT Now as our part to filling it,” Ryan says. “With a large global market for medical devices, which is estimated to reach US$440 billion by 2018, we see plenty of opportunities to leverage our hospital to commercialize innovative devices and technologies, and drive our economy.” William Charnetski, Ontario’s Chief Health Innovation Strategist, echoed Gary’s sentiments during his keynote at the incubator’s opening, saying the current innovation climate is “one of those times in history where (we are) on the cusp of something; People now are talking about using healthcare as an economic driver in this country.” With CreateIT Now in its new home, Southlake is seizing the moment to show that hospitals can be a driver of the economy. “CreateIT Now is a model for hospitals of the future,” says Williams. “Fostering health care technology is a catalyst to a more sustainable health care system. By working collaboratively with startups we can play a role in shaping the technology to best benefit our patients and the health ‘care sector, while also creating opportunities for Canadian companies to attract investment, create jobs, and close down H the innovation gap.” ■ Kathryn Perrier is a Media and Government Relations Specialist at Southlake Regional Health Centre.


Focus 11

Markham Stouffville Hospital’s Neonatal Intensive Care Unit.

Disinfecting NICU equipment for tiny patients By Peri Elmokadem atients visit hospitals to get better, and health care facilities do everything they can to deliver on that expectation. They adopt medical best practices and acquire state-of-the-art devices and technologies to ensure the best quality of care for their patients. However, what is often a challenge to institutions is ensuring that patients being treated do not contract infections from other patients, visitors or even health care workers in the facility.


Every year, more than 200,000 patients contract a health care-associated infection (HAI) while receiving healthcare in Canada. In February and March of 2015, Markham Stouffville Hospital’s (MSH) Infection Prevention and Control (IPAC) team found evidence of Extended-Spectrum Beta-Lactamase (ESBL) and Serratia transmission in the Neonatal Intensive Care Unit (NICU). In the process of managing this cluster, a few challenges were brought to the surface related to routine cleaning of hospital equipment, such as human error, the inability to see pathogens with the naked-eye and the time and logistical constraints imposed on the Environmental Services department by current hospital protocols – all of which can lead to increased risk of infection and potential outbreaks.

Every year, more than 200,000 patients contract a health care-associated infection (HAI) while receiving health care in Canada. “This challenges the basic purpose of caring for patients in a health care facility,” says Anson Kendall, IPAC Manager. “Not only does it cause more grief for patients and their families, but it also costs hospitals more resources to treat preventable HAIs. It’s important to reduce the risk of cross contamination to help break the cycle of infection transmission in health care facilities.” To address the need for advanced cleaning of shared patient equipment, MSH acquired and implemented the Nocospray© solution into its disinfection process – a high-capacity, low-cost, portable piece of equipment that helps to prevent the spread of diseases and deadly pathogens common in hospitals and health care settings. This small portable device applies a dry ionized hydrogen peroxide and colloidal silver solution (tested and reviewed by Health Canada) to commonly used hospital equipment. When used as indicated, this system can disinfect all hard surfaces in an enclosed area. “This machine’s ability to act independently of human biases to disinfect areas that are not accessible to staff makes it practical and effective for health care environments where time, space and resources are limited,” says Yves Crehore, Senior Infection Control Practitioner. MSH’s Maternal Child Services, IPAC and Environmental Services departments initiated an implementation and review of Nocospray© on NICU equipment. To test the results, IPAC plated NICU equipment before and after applying the Nocospray© solution to observe the presence and reduc-

tion of viruses, bacteria and fungal spores. After an incubation period of seven days, the agar plates were observed and compared for results (see figure 1). The implementation of the technology into MSH’s Environmental Services program has demonstrated efficacy against a broad range of infectious agents and has significantly reduced growth on various surfaces, including porous and textured materials, which can be difficult to clean manually. “It would require 30 hours of manpower to reduce the microbial load of these same NICU equipment pieces down to this level of disinfection,” says Mike Cabral, Manager of Support Services. “This effective method of sterilizing to reduce risks of HAIs from mobile and complex shared equipment among patients saves MSH time and money while yielding exceed-

ingly better infection control outcomes and higher standards of care for patients in our hospital.” Integrated with MSH’s current Environmental Services practice, this technology has proven to offer the hospital an effective, cost efficient, easy-to-use solution that eases the time constraints placed on staff. But ultimately, this soluti on enhances patientcare and contributes to MSH’s number one goal: to deliver safe, high-quality care to every patient who enters the hospital. To learn more about this initiative, email Follow @MSHospital and @MSHIPAC H on Twitter! ■ Peri Elmokadem is a Corporate Communications Associate at Markham Stouffville Hospital.

Figure 1: NICU equipment was plated before and after using the Nocospray application and growth was observes and compared after an incubation period of seven days.



12 Focus

Cover story

It is estimated that between 10,000 to 20,000 Canadians have died from opioids since 1995.

Treating chronic pain with opioids: We need to think differently

By Dr. David Juurlink ain, unfortunately, is all too common. We have a natural aversion to it, and many patients have the expectation that it should be treated with medication. This is understandable. But when it comes to treating pain with medication, we have a problem: our options are limited, and the drugs we have often don’t work very well. We typically start with painkillers such acetaminophen or anti-inflammatory drugs (ASA, ibuprofen, naproxen and a dozen others). But for some people they aren’t safe or they just don’t work. Increasingly, the next step is a trial of opioids – drugs like codeine, morphine, oxycodone, hydromorphone and others. These drugs are derived, directly or indirectly, from the opium poppy, and they are now taken by millions of North Americans daily. It is difficult to argue that this is a good thing. In the past, opioid painkillers were reserved for severe pain (for example, pain resulting from a fracture), cancer pain, or pain at the end-of-life. Opioids were rarely prescribed for chronic pain because doctors were fearful of the risks, including the development of addiction. In the mid1990s, the landscape began to change, and opioids were prescribed with increasing


frequency to millions with chronic pain. This change reflected a “new approach” (as it was cast at the time) to thinking about chronic pain. Eager to make their patients feel better, physicians accepted this new approach uncritically, oblivious to the lack of evidence supporting the practice. In fact, even 20 years later, no studies have shown opioid therapy to be a safe and effective long-term treatment for pain. Nevertheless, countless patients receive prescription opioids, often at inordinately high dosages. Many of them are being actively harmed by treatment, and it is estimated that between 10,000 to 20,000 Canadians have died from opioids since 1995. Patients who take opioids rapidly develop tolerance to the drugs. In other words, pain relief lessens over time, often leading patient or prescriber to increase the dose. Even regular users who follow their doctor’s advice to the letter develop physical dependence, which can make it difficult to lower the dose or stop therapy without developing unpleasant side effects. Many patients come to believe they need opioids to function normally, when in fact the drugs are needed to avoid experiencing opioid withdrawal. To make matters worse, as doses escalate, opioids can actually make


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Dr. David Juurlink pain worse. Few physicians and even fewer patients appreciate that opioid-induced hyperalgesia can actively undermine efforts to relieve pain, and increase the dose further in a desperate but futile search for relief. Even leading pain experts who once espoused the use of opioids for chronic pain now acknowledge that the role of these drugs needs to change. At the core of the discussion is a simple, unarguable principle of medical care: The benefits of a therapy should exceed its risks, ideally by a large margin. With opioids, this is clearly not happening. What changes should occur? An important first step is for doctors, pharmacists and nurses to help manage expectations about what pain medicines can and cannot do. Physicians and patients alike need better education about the many risks of long term opioid use. There should be a frank discussion between physicians and patients at the outset of therapy regarding the goals

What patients should ask their health care provider: • What are the various options of medicines for pain (drug and nondrug)? • What benefits can I realistically expect from this medicine? • Should I take this medicine regularly, or only when I have pain? • How and when will we know whether this medicine has helped? • What are the side effects of this medicine? If it isn’t helping my pain, will I be able to stop it easily? • Is there any aspect of my medical or family history that makes this medicine especially risky for me? • Is it safe to take this drug with my other medications? What about with alcohol? • How might this medication impact my other medical conditions?

of treatment, with a clear “exit strategy” if those objectives are not met. Prescribers must resist the urge to increase the dose of opioids in response to ongoing pain. Continued pain is expected, in part because opioids aren’t as good at treating chronic pain as we’ve been led to believe, and in part because of the development of tolerance as noted above. In early 2016, it is anticipated that the United States Centres for Disease Control and Prevention will publish new guidelines for the use of opioids in chronic pain, recommending a threshold dose of 90 milligrams of morphine (or equivalent) per day. If heeded, this recommendation alone could save hundreds or perhaps thousands of lives every year. We also need to emphasize the importance of non-drug therapies in certain pain states. For example, exercise can significantly benefit patients with fibromyalgia, while weight loss can lessen pain from osteoarthritis. While these interventions are more difficult than simply taking a pill, non-drug interventions can sometimes go a long way toward helping patients improve quality of life while limiting the use of opioids. We practice in a culture that expects (and to a certain extent facilitates) the prescribing of medication for many of life’s challenges, including pain. Sometimes opioids are needed, but for many patients with chronic pain they afford more harm than their benefits justify. We have to rethink how we treat pain. Until we have better drug therapies, we must respect a fundamental tenet of medical practice: never make the treatment worse than H the disease. ■ Dr. David Juurlink is a professor of medicine, pediatrics and health policy, management and evaluation at the University of Toronto. He is head of the division of clinical pharmacology and toxicology at Sunnybrook Health Sciences Centre and a medical toxicologist at the Ontario Poison Centre at the Hospital for Sick Children. He is senior core scientist at the Institute for Clinical Evaluative Sciences.


Focus 13

Championing accreditation readiness By Ania Basiukiewicz n November 2013, Trillium Health Partners achieved its first formal Accreditation as a three-site hospital. Getting to this point as a recently merged organization offered a unique learning opportunity, and a chance to highlight the new organization’s commitment to quality and excellence through extraordinary teamwork across the hospital’s three sites. “The staff at all sites are committed and engaged. Enthusiasm is a hallmark of all the care teams that were encountered during the Accreditation Survey,” said Accreditation Canada’s surveyors during the formal debrief at Trillium Health Partners. “At the care team level, managers have empowered their employees, which have contributed to the engagement of the staff.” As Trillium Health Partners staff reflected on what it takes to embed leading practices into organizational culture, an important question came up. “I thought – if incorporating best practices into our daily activities is really important, then why don’t we do better at focusing on them every day?” says Jarmila Grof, Clinical Educator, Trillium Health Partners. “It’s about accountability; it is everyone’s responsibility to practice according to the latest standards and evidence. You wouldn’t want to dine in a restaurant that did not pass its health inspection. The same translates to us: we want to work in an environment where quality of care and patient and staff safety is a top priority, and where we have the highest expectations of one another to achieve that,” adds Grof. This question and the commitment from the front lines led Trillium Health Partners’ leadership to develop a comprehensive Accreditation Sustainability Plan, helping to champion best practices within the hospital. The plan is a unique, leader-led championship model that looks at innovative ways to integrate patient safety and quality standards into daily operations. Since its implementation in November 2014, the plan has already shown significant impact on patient care and experience. “The sustainability work has helped us translate the expectations set out by Accreditation Canada to simple, tangible examples of how we embed its recommendations into our day-to-day practice,” says Heather Ead, Clinical Educator, Trillium Health Partners. The plan includes an interactive audit conducted across the organization every three- four months by “mock tracers” reviewing key quality practices across different program areas, as well as a thorough sustainability assessment similar to performing a mock accreditation, but on a smaller-scale. It is designed to determine which key quality practices have been successfully adopted into the hospital’s daily routines, and to identify gaps. In November of 2016, a simulated survey will be conducted by the hospital’s in-house surveyors and quality team members. This will provide a baseline assessment to inform the planning for the hospital’s next Accreditation Canada Survey in November 2017.


You wouldn’t want to dine in a restaurant that did not pass its health inspection. The same translates to us: we want to work in an environment where quality of care and patient and staff safety is a top priority, and where we have the highest expectations of one another to achieve that.

Trillium Health Partners staff with in-house surveyor, Cathie Badeau, during a ‘mock tracer.’. Since launching the Accreditation Sustainability Plan, the team has conducted 77 mock tracers across various program areas and has engaged more than 74 patients, all to enforce and assess day-to-day practices. “Our mock tracers encourage open communication with our surveyors about quality and patient safety practices. Through these experiences, our front line team members have made excellent suggestions on where and how improvements can be made,” says Tara McCarville, Vice President, Quality, Enterprise Risk & Business Intelligence. “It’s also been encouraging to hear from our patients. Their first-hand input has helped us refine our quality and patient safety program, and how to reinforce what we are doing right, and highlight what we can do better to improve their care,” McCarville adds. In a mock tracer event, one patient noted, “I feel safe here. It cannot be understated how important these relationships with the teams are. They make the experience positive; they provide hope and make it feel like home. I actually look forward to coming for my treatments.” “Kudos to Trillium Health Partners for supporting a program that has embedded accreditation into its fabric as an ongoing program of quality improvement,” says Dr. Norman Hill, Vice President, Medical Administration, and in-house surveyor at Trillium Health Partners. “Accreditation shouldn’t be looked on as a necessary project that comes around every four years, but as a mechanism by which we can continuously improve the quality of care we deliver to our community every day.” Trillium Health Partners is the largest community hospital serving residents in Mississauga and West Toronto. The hospital’s Accreditation Sustainability Plan is a proactive approach allowing a continuous, sustained focus on best practices to

deliver quality, safe care, and has the hospital well positioned to undergo its second H formal Accreditation in 2017. ■

Ania Basiukiewicz is a Communications Advisor at Trillium Health Partners

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14 Focus


A new era in kids’ healthcare By Dr. Peter Fitzgerald omething pretty amazing in kids’ healthcare happened in Hamilton last month, something that was 25 years in the making. For the first time, McMaster Children’s Hospital programs in autism spectrum disorder, developmental pediatrics and rehabilitation, and outpatient mental health for children and youth have come together under one roof, in purpose-built space that is just as beautiful as it is functional. The Ron Joyce Children’s Health Centre had its official ribbon-cutting on Nov. 17, after 18 months of construction, five years of intense planning and decades of a clung-to vision that the best way to serve young people with lifelong health challenges is in a place created specifically for them. This new facility is part of McMaster Children’s Hospital, but you won’t see ambulances pulling up at the door – this isn’t acute care and there are no beds. This is where children will learn to walk despite physical challenges. Where kids with autism-related behavioural issues will learn how to cope with school and social settings. Where teens suffering from depression or other mental-health problems can come for restorative therapy. It’s where mothers and fathers learn the techniques to care for their special needs kids, and where we work together to monitor and celebrate every achievement and every milestone. For decades these children’s health care programs were located at Hamilton Health Sciences’ Chedoke site, where they were housed in a series of buildings dating back to the days when Chedoke was a tubercu-


losis sanatorium. We called the services, collectively, the Child and Family Centre. Also housed at Chedoke, and now moving to the Ron Joyce Children’s Health Centre, were the renowned Prosthetics and Orthotics and Audiology departments, which serve both children and adults. While the quality of the care provided has always been top-notch in each of these programs, the environment for patients wasn’t optimal, and working collaboratively was made more challenging by being located in a variety of buildings. As the president of our children’s hospital – and one of our doctors – I’m excited about this new era in care for children with challenges such as cerebral palsy, Down syndrome, spina bifida, autism, mentalhealth problems and other developmental hurdles. They now have a treatment facility to call their own, a place designed for them. Every detail of the building – from the style of the front entrance to the width of the hallways to the colours of the paint on the walls – was chosen with patients’ needs at the front of our minds. In fact, patients and families were on our numerous working groups that helped shape the design of the building and make it the showcase it is. The new building, with more than 300 staff facilitating an anticipated 70,000 visits annually, gives us room for the future growth that is always on our minds, given the local and regional responsibilities of McMaster Children’s Hospital. And locating it in Hamilton’s North end improves access particularly for families in the urban core. Some years ago Hamilton city council took up the vision “best place to raise a

The Ron Joyce Children’s Health Centre, park of McMaster Children’s Hospital, opened on November 17th. Every detail of the building — from the style of the front entrance to the width of the hallways to the colours of the paint on the walls — was chosen with patients’ needs at top of mind. child” to describe our city’s aspirations. I believe our McMaster Children’s Hospital is an integral part of making that vision a reality. Some special features of the Ron Joyce Children’s Health Centre: • Outdoor therapeutic playground themed to represent Hamilton’s bridges, steel mills and waterways. • Wheeling track where children testing out wheelchairs or other mobility devices can practice on the 180-metre track. • The centre is Silver LEED-certified for its energy-saving features and extensive

greening of the exterior property. Almost 200 trees are being planted. • Youth-centred art and sculpture can be seen on every floor of the RJCHC, including the atrium’s multistorey solar system representation. • Therapeutic gym with electronic gait measurement and harnesses to give nonwalking children the experience of being H on their feet. ■ Dr. Peter Fitzgerald is President, McMaster Children’s Hospital, Hamilton Health Sciences.

The Ron Joyce Children’s Health Centre had its official ribbon-cutting on Nov. 17, after 18 months of construction, five years of intense planning and decades of a clung-to vision that the best way to serve young people with lifelong health challenges is in a place created specifically for them. HOSPITAL NEWS DECEMBER 2015


Focus 15

Earning a top level rating from Accreditation Canada By Laura Dockstader

ith recognition for successful engagement with community partners, patients and families across all areas of care, St. Joseph’s Health Care London (St. Joseph’s) has been awarded Accreditation with Exemplary Standing from Accreditation Canada, the highest designation awarded through the hospital accreditation program. St. Joseph’s has received this designation for the second consecutive time. Through the accreditation process, organizations are evaluated based on their performance against many national standards of excellence and required organizational practices (ROP) for quality and patient safety. Accreditation surveyors spend close to a week onsite at an organization, reviewing


What is Accreditation? Accreditation Canada is a not-forprofit, independent organization which provides national and international health care organizations with an external peer review process to assess and improve the services they provide to their patients and clients based on standards of excellence. Health care organizations that participate in Accreditation Canada’s accreditation programs are evaluating their performance against national standards of excellence. These standards examine all aspects of healthcare, from patient safety and ethics, to staff training and partnering with the community. The accreditation decision an organization receives is based on its performance in three main areas and reflects the organization’s degree of success in each area: • meeting the requirements embedded in the standards; • achieving applicable Required Organizational Practices;* • soliciting feedback from their staff on worklife quality and patient safety culture. Accreditation Canada provides four different levels of awards: no accreditation, accreditation, accreditation with commendation, and the highest recognition accreditation with exemplary standing. As noted by Accreditation Canada, a decision of “Accredited with Exemplary Standingâ€? means an organization has attained the highest level of performance and quality in achieving the majority of required elements in the accreditation program. *Required Organizational Practices (ROPs) are evidence-based practices that mitigate risk and contribute to improving the safety of health services.

documentation and performance data, observing care processes, interviewing patients, families, staff, physicians, and community partners. St. Joseph’s was compliant on all ROPs, and was successful in meeting 1719 of the total 1727 applicable accreditation standards evaluated – showing that we successfully met 99.5 per cent of the requirements. “Only 16 per cent of organizations surveyed with Accreditation Canada have an Exemplary designation. This outstanding achievement illustrates our commitment to quality and excellence across all aspects of the care we provide. We are so proud of the demonstrated focus our staff and physicians have on patient safety, engagement and quality every day,� says Dr. Gillian Kernaghan, St. Joseph’s President and CEO. St. Joseph’s leaders were delighted to receive many positive comments from the surveyors about the care that we provide and the strong cultural identity that is evident across St. Joseph’s. We were also fortunate enough to experience an additional, unique dimension to our accreditation survey this time. A delegation of three physicians from Kuwait accompanied the surveyors as observers for every part of the process. The delegates were truly enthusiastic about their visit, particularly with what they witnessed first-hand during the survey. One of the observers, Dr. Talal Al Fadalah, shared his feelings about the experience and the impact it had. Dr. Al Fadalah is a Quality Officer with Kuwait’s Quality and Accreditation Directorate, the main government body responsible for ensuring the quality and safety of public health care services in Kuwait. While attending an interview session, Dr. Al Fadalah noticed on the wall a large poster featuring the mission, vision and values of St. Joseph’s; he wondered if he would see those values in action. “And the answer is, I found more than that,� says Dr. Al Fadalah. “Everyone creates values and they are in boardrooms everywhere but here, people know the values and they are translating them into action. I’ve never been in an organization like this.� Most impressive, says Dr. Al Fadalah was how team members supported each other during meetings with the surveyors and the care he saw provided to patients. “I felt they treated patients as family members. This is the truth. This is what we felt. This is what we saw.� The entire experience – ‘and the wonderful results – have resonated deeply with St. Joseph’s staff, physicians, leaders and volunteers, as they now turn to incorporate what they’ve learned into their work across the organization. Dr. Kernaghan reflected, “We look forward to taking feedback from our survey and

Dr. Al Fadalah with St. Joseph’s Health Care London’s Mission/Vision/Values statement. translating that into our daily practice. At St. Joseph’s, the accreditation process is a continuous effort, bringing our strategic, performance and team efforts together to provide quality care, and supports our quest to realize our vision

to earn complete confidence in the care H we provide.� ■Laura Dockstader works in Communications & Public Affairs at St. Joseph’s Health Care London.


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16 Focus


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Accreditation Canada’s President and CEO Q: You started with Accreditation Canada in 2004. What was your interest in joining the organization? A: First of all, my commitment both personally and professionally has always been to the importance of quality and safe healthcare, ensuring that patients and families are at the centre and are treated with dignity and respect. And I believe in the power of accreditation. My personal goal was to make a difference. Having been an Accreditation Canada surveyor since 1992 and on the Board of Directors for six years, stepping down in 2002, I had ideas on how to increase the relevancy and value of accreditation.

Q: What were the priorities you felt needed to be addressed? A: The first was to increase the profile and value of Accreditation Canada to our stakeholders, partners, and the public. This meant we needed to look at our value proposition. We asked ourselves, how can we improve the relevancy and contribution of the organization? It was clear that we would need to take steps to improve the accreditation program, and position it more as a quality improvement tool and methodology, instead of a project. The second was developing Qmentum – not just the program, but everything that went into supporting and marketing it as well. Also important was developing regular ongoing communication with existing and new stakeholders and partners, as well as government. We needed to raise accreditation up from being somewhat hidden and behind the scenes to being a recognized and valued partner in any discussions regarding quality in healthcare.

Q: We know that hospitals have been involved in accreditation for many years. Do you think it is important for other sectors to also be accredited? A: Accreditation should follow the patient journey. Optimally, accreditation moves from primary health care to hospice palliative care and all health care encounters in between. Accreditation Canada is proud of the fact that our program is present in many sectors across the continuum, and our involvement continues to grow. Quality is about care across and throughout the system. HOSPITAL NEWS DECEMBER 2015

Q: What do you see as the major challenges for accreditation going forward? A: To continue being responsive to the realities of healthcare and health care system issues. It is imperative to ensure the Qmentum program is relevant and positively contributes to improving outcomes and efficiencies.

Q: Accreditation is all about best practices. Can you give an example of the most significant shift in your accreditation program that reflects best practice? A: Qmentum is the biggest shift. It’s a unique program that sets the bar for best practices in accreditation. Increasingly, other organizations that are developing accreditation programs are learning and benefiting from our experience. Required Organizational Practices – ROPs – would be another example. Including ROPs in the accreditation program in 2005 with their focus on patient safety nationally and internationally was a major shift. Initially ROPs were seen by health care leaders as an unnecessary component. Some felt they were a little “top down.” It’s true they contained more rigour than other program components. But when we evaluated Qmentum in 2011, the ROPs were identified as the major strength of program. More recently, the most significant shift is client-and family centred care (CFCC). Work on strengthening this component began in 2013. A focus on CFCC is now woven throughout the Qmentum program. This will contribute in measureable ways to raising the bar by seeing clients and families as true partners, enabling them to provide valuable input into planning and decision making, either for their own personal care, or towards improvements to a program or an organization.

Q: How does Accreditation Canada work with other organizations to advance quality and safety? A: We do this through sharing research and our many partnerships with other like-minded organizations, such as the Canadian Patient Safety Institute (CPSI). Everything we do is done with, and in consideration of, the relevant stakeholders or partners. With the challenges everyone faces, it is critical that quality and safety organizations work together. We must complement each other’s efforts. At Accreditation Canada, we are the process experts, not the content experts. The content of our program is thanks to the expertise that comes from individuals

Wendy Nicklin and associations across the country, and through evidenced-based research and literature and pre-existing guidelines. No one organization can do it alone.

Q: How does Accreditation Canada encourage knowledge transfer? Accreditation is all about transforming knowledge into action. We have a strategic commitment to strengthen knowledge transfer beyond the standards and the on-site survey. This means being actively involved in conferences, increasing our number of reports, continually developing the Leading Practice Database, and publishing Quality Matters. Since 2011, we have been mining our database to issue reports that inform key stakeholders of health care trends – painting a picture of quality by sector and province. These include reports to government that profile the aggregate accreditation results for their jurisdictions. We also produce a variety of joint reports with our partners, including our recent report with the Canadian Home Care Association, Advancing Quality Improvement and Integrated Care.

Q: We understand you will be leaving Accreditation Canada at the end of this year. What are your future plans? A: Accreditation Canada has been actively involved with the International Society for Quality in Health Care (ISQua) for a number of years. I have served as Chair of ISQua’s Accreditation Council for their International Accreditation program (IAP) and have been a board member for six years. I was recently elected to be Presidentelect of ISQua (equivalent to a Board Vice-Chair). It is a six year commitment and I’m looking forward to it. My goal is to remain active in the quality and safety arena internationally as well as in H Canada. ■ Wendy Nicklin is the outgoing President and Chief Executive Officer of Accreditation Canada, a position she served in for 11 years. A recognized health care leader across Canada and internationally, she has lead a significant renewal of the approach to and value of accreditation.

Safe Medication 17

Insulin: A high-alert medication “The patient noticed his insulin box was different than [what] he had before. He should have received Novolin® ge NPH and had been given Novolin® ge 30/70 in error.” By Carolyn Kasprzak and Certina Ho nsulin is one of the most wellknown medications available on the market as diabetes is an increasingly prevalent disease in Canada. Whether in the hospital or community setting, insulin use is widespread. In hospital, insulin is routinely the treatment of choice for admitted patients with diabetes and in the community, patients with type 1 diabetes and many patients with type 2 diabetes self-administer insulin at home. Insulin is consistently recognized as a high-alert medication, meaning that it has the potential to cause detrimental patient harm when used in error. If given as an excessive dose, insulin may cause life-threatening seizures and coma due to hypoglycemia, while an under-dose of insulin may lead to life-threatening ketoacidosis or hyperosmolality related to hyperglycemia.


Insulin has been consistently identified as one of the top medications associated with medication incidentrelated harm to patients To examine medication incidents involving insulin occurring in the community, ISMP Canada evaluated 81 insulin-related medication incidents voluntarily reported to the Community Pharmacy Incident Reporting (CPhIR) program ( The incidents were categorized into four main themes and further subthemes based on common characteristics (Table 1). Potential contributing factors (Table 2) were then identified, from which system-based recommendations were developed to enable health care providers to prevent these insulin-related medication incidents from recurring.

Product selection (related to unique insulin properties) Insulin may be administered by a syringe, a pen, or a pump. There are various insulin preparations available, such

as, rapid-acting, short-acting, long-acting, and pre-mixed. In addition, patients often use multiple insulin products. This may lead to insulin product mix-up at various stages of the medication-use process, particularly, prescribing, order entry and dispensing. Significant patient harm may occur if the wrong insulin product is selected and administered. In order to prevent insulin product mixup, prescribers should consider using standardized pre-printed orders. Pharmacy order entry and dispensing software should include both generic and brand names for insulin with warning flags to alert for potential product mix-up. Independent double checks are recommended throughout the pharmacy workflow and medication-use process, including an overview and confirmation of the insulin product(s) that the patient uses at prescription dropoff and pick-up. Lastly, insulin products should be stored and segregated in the fridge according to the onset of action (e.g., rapid-acting, short-acting, long-acting, and pre-mixed) instead of by the alphabetical order of the product name.

Therapeutic regimen change Due to the progressive nature of diabetes and the multiple factors affecting blood glucose, patients often require or experience frequent insulin regimen changes, such as, a change in dose, change in insulin product, or an addition of another insulin product. Often insulin-related medication incidents occur after a patient’s therapeutic regimen has changed. Therefore, health care practitioners should have adequate communication with the patient with regards to any regimen changes. A comprehensive diabetes-focused medication review is recommended whenever a patient has a significant change in insulin usage to ensure the safe use of insulin by the patient.

Dosage calculations Insulin dispensing typically involves the calculation or conversion of insulin units to milliliters, and then to the total quantity that needs to be dispensed for a duration of supply to the patient. Additionally, insulin syringes are available in different sizes, holding different amounts of units. Medication incidents may occur if the wrong dose is calculated, an incorrect amount of medication is drawn up in

Table 1: Main Themes from a Multi-Incident Analysis of Insulin Medication Incidents Main Themes Product Selection (related to unique insulin properties)

Subthemes Prescribing Order Entry Dispensing

the syringe, or if the patient receives the wrong number of days of supply of insulin. Policies should be developed for independent double checks among pharmacy staff members when preparing or dispensing insulin prescriptions to patients, for instance, by documenting handwritten calculations for insulin quantity during order entry followed by an independent calculation and verification by a different team member during the dispensing process.

Storage requirements Insulin requires adequate refrigeration to preserve drug stability until administration. Medication incidents occur when insulin is accidently left outside of the fridge. Therefore, policies and procedures with regards to dispensing refrigerated products should be developed and reinforced. For example, refrigerated medications should always be returned to the fridge immediately after filling for proper storage until patient is ready to pick up the prescription. Overall, while insulin is a vital medication for many patients with diabetes, it must be used with vigilance to prevent unnecessary patient harm. Table 2 provides a summary of possible contributing factors to insulin medication incidents that have been identified from this multi-incident analysis. ISMP Canada recommends using system-based solutions to prevent insulin medication incidents in all practice H settings. ■ Carolyn Kasprzak is a Pharmacist at Quinte Health Care and a consultant at the Institute for Safe Medication Practices Canada (ISMP Canada); Certina Ho is a Project Lead at ISMP Canada.

Storage Requirements

• Variety of dosage forms are available for insulin products (e.g., rapid-acting, short-acting, long-acting, premixed, vials, cartridges, preloaded pens) • Multiple formulations are available for the same insulin type • Look-alike, sound-alike (LASA) drug names and LASA packaging of insulin products • Proximity of storage of LASA insulin products in the fridge • Patients may using multiple insulin products for their disease management concurrently • Frequent insulin regimen changes and adjustments may be required for medication therapy management of patients with diabetes • Unique dosage calculations are required during the dispensing of insulin products (e.g., conversion from units to mL and the number of days’ supply) • Variety of insulin syringe sizes are available • Unique storage requirements (i.e. refrigeration) for insulin products

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Therapeutic Regimen Change Dosage Calculations

Table 2: Possible Contributing Factors to Insulin Medication Incidents

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18 Focus


Prescription for crisis relief:

Unique hospital – community partnership helping hundreds By Kathleen Bain ver the past three years, a quiet evolution in healthcare between North Bay Regional Health Centre (NBRHC) and a community partner has benefited more than 500 people needing crisis help, and checked all the boxes for today’s new way of delivering care. Peer Support Navigators from North Bay’s PEP (People for Equal Partnership in Mental Health) – who have their own ‘lived experience’ with mental health and addictions – are in the hospital’s emergency department (ED) to offer ‘soft’ supports to those in crisis. The NE LHIN, hospital and PEP worked together to implement the concept of peer support navigation/crisis intervention as a complement to the ED’s clinical care. “The program has been an extraordinary team effort between us and the hospital,” says Joel Johnson from PEP’s management team. “Our Peer Support Navigator at the ER is like a warm blanket on a cold night.” Peer Support is one of the local initiatives that has helped to reduce the rate of NBRHC’s repeat emergency


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visits from people with mental health conditions. “Ingenuity and teamwork in the community of North Bay has proven successful in both increasing faster access to care for people living with mental health issues and decreasing the number of visits to the hospital’s emergency department, says Louise Paquette, CEO of the NE LHIN. “Faster access, better wait times, and more coordinated care – this is what people want out of their health care system.”

“Our Peer Support Navigator at the ER is like a warm blanket on a cold night.”

Terri McIntosh, Crisis InterventionTeam Lead at NBRHC, explains that visits to the ED can be very stressful for people having difficulties with mental health and/or addictions. “The Peer Support Navigators have been most beneficial for these patients because they share their own lived experiences, enabling an effective connection. There is a trust and mutual understanding that makes the patient feel more at ease,” she says. Paul Heinrich, NBRHC President and CEO, explains, “Peer Support Navigators can connect patients with mental illness and/or addictions with community peer supports which enables the patient to remain in the community while receiving the appropriate services/supports. We are very fortunate to have such a reliable and trustworthy community partner in PEP.” Johnson says that three themes have occurred throughout PEP’s three-year partnership with NBRHC. “Year one, we proved ourselves to the hospital environment (60 people were

helped). In year two, the hospital environment proved to itself that PEP’s peer supporters were valuable (200 people were helped). Now, in year three, we’re proving to each other how effective and valuable this is (more than 300 people helped).” “Peer Support Navigators are part of an amazing partnership effort with NBRHC administration and staff to make care more seamless,” says John Bowcott, Executive Director of PEP. Kyle Larente, Peer Support Navigator is in his third month of work with PEP, and knows very well about the benefits of personal support. He suffered from high anxiety and depression, and now 10 years later, says he is doing a lot better. “I never had access to peer support; only the clinical model,” says Kyle. “Now I like to provide a bridge between those models.” Kyle says communication is key. He talks with people about how they’re feeling and about coping mechanisms. Peer Support Navigation help includes connections made to community supports, housing or food, and sometimes support for family members. (Read Kyle’s description of his work in the sidebar)

FACTS: • In addition to Peer Support Navigators, the NE LHIN has implemented a number of other initiatives to decrease re-visits to emergency departments, such as expanding opiate programs for pregnant and parenting moms, and increasing addictions housing and case management options. • A PEP Peer Support Navigator is available at North Bay Regional Health Centre’s ED on weekdays from 2 to 9 p.m., and on weekends from 11 a.m. to 4 p.m. • 20 per cent of Canadians will personally experience a mental illness in their H lifetime. ■ Kathleen Bain is a Communications Officer with the NE LHIN.

Kyle Larente is a Peer Support Navigator for North Bay’s People for Equal Partnership in Mental Health. The navigators are in the emergency department (ED) to offer ‘soft’ supports to those in crisis.

A PEP-employed Peer Supporter describes his work in the Emergency Department at North Bay Regional Health Centre… My name is Kyle Larente. I am a Peer Support Specialist with People for Equal Partnership in Mental Health (PEP) and a recent graduate of the Mental Health and Addictions program at Canadore College. My role as a peer support worker, as well as a counsellor, means that I have the rare benefit of being able to toe the line between the peer and clinical models, allowing me to listen emphatically to people in need and provide them with options for coping strategies, brief behavioural interventions, and psychoeducation that they can benefit from. The benefit of peer support is the fact that I can also do this as someone who has survived from more than a decade of anxiety and depression, who has also walked the same system, been on some of the same medications, and managed to move away from it. I do not prescribe my own journey through the mental health system as a panacea to cure every person, but I provide them with living proof that it is possible for them to walk their own path, one that is meant specifically for them and leads to a place of stability and happiness. I wake up for work every day hoping to be able to give that hope to at least one person.


Focus 19

Building the future of health care for children and women in British Columbia

By Angela MacKenzie

ovember marked two years until the Teck Acute Care Centre (TACC) opens its doors to patients on the Vancouver campus of BC Children’s Hospital and BC Women’s Hospital + Health Centre. Construction is moving ahead rapidly with work underway on the top floors of the building. The scope and scale of the new facility is no longer difficult to envision. “Although the pace of progress on site is very impressive, it is hard to believe that the whole building will be complete and open to patients in about 24 months,” says Dave Ingram, Chief Project Officer, BC Children’s and BC Women’s Redevelopment Project. Construction began in May 2014 and when the new TACC opens in November 2017, it will be 59,400 square metres (640,000 square feet) in size and feature eight floors of clinical space. It will provide expanded and enhanced clinical space, single-patient rooms and integrated technology and equipment. It will also have the integrated clinical spaces and resources to accommodate teaching and research. “The new hospital will transform the delivery of care to children, their families and women of B.C.,” says Ingram. The BC Children’s and BC Women’s Redevelopment Project is building the TACC on the Vancouver hospital campus as part of a three-phase redevelopment


The new Teck Acute Care Centre on the Vancouver campus of BC Children’s Hospital and BC Women’s Hospital +Health Centre will open its doors to patients in less than 24 months. under the leadership of the Provincial Health Services Authority (PHSA). The project is being delivered as a publicprivate partnership (P3) through a 30-year agreement with Affinity Partnerships to design, build, finance and maintain the TACC. On the west side of the building, work is underway to complete the concrete structure of the top floors. Meanwhile, several levels of the east side of the building

have been completed and rapidly progressing upwards. “We’re the tallest building on the Oak Street Campus,” says Ingram. “Inside, we’re already starting to work on the rough-ins, where the electrical wires are going to run, where some of the mechanical ducts are going to run, where the partitions are going to come up to separate out some of the rooms inside the new facility.” The main floor for the new Ledcor

Children’s Emergency Department and Lee Family Diagnostics and Imaging Area is taking shape. The second and third floors will house the Neonatal Intensive Care Unit (NICU), Birthing, Transfusion Medicine, Procedures Suites, Pharmacy, Alex Skidmore Renal Dialysis Unit and the Milk Handling Room. The fourth floor will be home to the Hudson Family Pediatric Intensive Care Unit and the ANOM Special Procedures Suites, while the fifth floor will house the medical device reprocessing department and mechanical and electrical. The sixth and seventh floors will treat medical/surgical inpatients, and the Capstone Mining Corp. Oncology Unit, the hematology/bone marrow transplant units and a s atellite pharmacy will be located on the eighth floor. The next phase of construction work will focus on installing the dry wall and the exterior cladding while the structure is still being built upwards. “I think it’s great to see people so excited now that it’s starting to take shape,” says Ingram. For more information about the project, H visit ■ Angela MacKenzie is a Communications Officer for the BC Children’s and BC Women’s Redevelopment Project.



20 Focus

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Focus 21

The future of healthcare needs improved collaboration By Dr. Mike Toth ransformation is a popular buzz word – particularly in healthcare where we’re always looking for better ways to deliver care. As we look to the future of healthcare, transformation won’t be just something we talk about – it will be something we have to do to meet the needs of our growing and aging population. We all know our population is aging. A recent Statistics Canada report projected that seniors would account for a quarter of the population within the 25 years. It showed the number of people 75 and older will triple in the next 25 years. And it revealed, for the first time, we are a country of more seniors than children. What does this mean for the health care system? It means we will be caring for an increasing number of patients with chronic diseases such as diabetes and hypertension. It means there will be greater demand on our publicly funded health care system. It means transformation and innovation will be necessary in order to provide our patients with the kind of quality, patient-focused care they need and deserve.


This kind of transformation will take partnership. Health care providers of all stripes must get better at working together in our efforts to put patients first. We must get better at communicating, at integrating, and at working collaboratively. The government is a key player in that equation and in Ontario the future looks uncertain if the current approach to managing our health-care system continues. Faced with a challenging financial situation, the government has made the choice to flat-line hospital budgets, which has meant staff layoffs, bed closures and reduced operating room hours – all of which decrease access to care for patients. When it comes to Ontario’s doctors, the provincial government is not working with the 28,000 physicians who deliver front-line care to patients across the province every day. We are concerned by the almost seven per cent in unilateral cuts since February 2015 the government has made to physician services expenditures, which cover all the necessary care doctors provide to patients every day. Continued cuts are not sustainable and it’s not the formula for the kind of health care our patients need today or in the years to come.

I believe this transformation and partnership is possible. We’ve done it before. It is through working together that physicians and the government transformed primary care. We moved towards group-based models of care that include family health teams where physicians and nurses work alongside other ancillary health care providers such as registered dieticians and social workers to provide comprehensive care to a range of patients.

Health care providers of all stripes must get better at working together in our efforts to put patients first. We must get better at communicating, at integrating, and at working collaboratively. A recent study in the Canadian Medical Association Journal (CMAJ) found there are many benefits with these kinds of interprofessional teams – in particular

patients with diabetes have improved outcomes. There is more work to be done on this front, but instead the government pressed pause on many of the groupbased models of care with the unilateral changes it imposed on physicians in February of this year. It is these models of care that made family medicine an attractive area to practice once again and for the sake of the more than 800,000 people in Ontario without a family doctor we can’t afford to go backwards. The Ontario Medical Association has an idea on how to leverage the interprofessional teams that exist today to provide care to those complex patients who could benefit from seamless team-based care. The government has ideas, too. Neither of us can do it alone and the people of Ontario expect us to work together to address the issues that will make our health care system sustainable into the future for them and their families. Let’s work together to put patients H first. They deserve nothing less. ■ Dr. Mike Toth is President of The Ontario Medical Association.


22 Focus


A good year for health care

infrastructure By Nancy Kuyumcu

n looking back on Ontario’s infrastructure landscape over the past 12 months, 2015 was a year abounding with construction activity, and much of it occurred in the health care sector.


Since its inception in 2005, Infrastructure Ontario (IO), the Crown agency responsible for delivering public infrastructure on behalf of the province through public-private partnerships, has completed 34 projects in the health care sector alone,

Casey House (Toronto) This past spring, construction began on a new facility for Casey House, a freestanding specialty hospital in Toronto for patients with HIV/AIDS. Once complete, the 58,000-sq.-ft. treatment facility will enable Casey House to introduce a new model of care, while increasing its capacity to accommodate new programs and updated building design standards. The new facility will include 14 private in-patient beds, including two respite beds, space for a day health program and community programs, therapy rooms, office space for homecare program staff, and new spaces for administrative and support services. The project is expected to be completed in late 2016.

while 12 health care projects are under construction. Together, these projects are worth more than $14.14 billion combined and are designed to modernize the province’s aging infrastructure and improve access to services.

Here’s a look at a few projects that H reached major milestones in 2015. ■ Nancy Kuyumcu is a Communications Advisor with Infrastructure Ontario.

ErinoakKids Centre for Treatment and Development (Brampton, Mississauga and Oakville) Earlier this year, ErinoakKids Centre for Treatment and Development celebrated the start of construction on three new children’s treatment centres – in Brampton, Oakville and Mississauga. The new centres will consolidate ErinoakKids’ existing patchwork of 11 facilities in Halton and Peel and enable the organization to continue its mission to help children and youth with physical, developmental and communication disabilities achieve optimal levels of independence and wellbeing. Among the services to be offered at the new facilities are autism, infant-hearing and blind low-vision services, physiotherapy and occupational therapy, speech and language services, assistive-devices resource services, medical, nursing and specialty medical services, respite services and family support services. The new centres are slated to open in 2017.

Humber River Hospital (northwest Toronto) In October, the new Humber River Hospital officially opened for patient care. Built using the design principles of “lean, green and digital,” the new facility uses the best possible technology to support the delivery of patient-centred care and is the first fully digital hospital in North America. With increased capacity from 549 to 656 inpatient beds, expanded emergency services, increased specialized outpatient services and updated infectious disease containment systems, the 1.8-millionsquare-foot hospital offers greater access to high-quality acute-care services for patients and families.



Focus 23

Milton District Hospital (Milton) This past summer, Halton Healthcare celebrated the start of construction on a long-awaited expansion and renovation of its Milton District Hospital. A critically important hospital for the residents of this town, the Milton District Hospital will receive a new four-storey patient care building and significant renovations to the existing facility. Through this expansion, patients will benefit from an increase in the number of beds – from 63 to 129 – a new MRI machine and other expanded services, such as emergency, surgical, critical care, maternal newborn and diagnostic imaging. Ample single-patient rooms will improve infection prevention and control measures, while providing more privacy and a quieter healing environment for patients. The project is due for completion in spring 2017.

Oakville Trafalgar Memorial Hospital (Oakville)

Peel Memorial Centre for Integrated Health and Wellness (Brampton)

After four years of construction, Halton Healthcare’s new Oakville Trafalgar Memorial Hospital opened its doors to patients on December 13. As one of the largest hospital redevelopment projects in Ontario, the 1.6-million-sq.-ft. facility boasts capacity for 457 inpatient beds – 80 per cent of which come with private single-patient rooms. A sleek, sunlight-filled design complements the calm, quiet outdoor spaces. The new hospital provides increased capacity for a full range of acute care, obstetrical, surgical, emergency, mental health and ambulatory services, along with a cancer clinic, a new service for Oakville. The new facility replaces the old Oakville hospital, which is now closed.

Brampton is one step closer to receiving a new health centre. This summer, William Osler Health System marked a significant milestone when it celebrated “topping off” on its Peel Memorial Centre for Integrated Health and Wellness. Topping off is when construction reaches the highest point on a building. Once complete, the Peel Memorial Centre will be a state-of-the-art ambulatory care facility, providing such services as urgent care, day surgery, women’s, children’s and adolescent health, seniors’ rehabilitation and wellness, day clinics for dialysis, preventive care for chronic conditions, diagnostics, laboratories, and mental health and addictions treatment and supports. Substantial completion of the project is expected in fall 2016.

Ron Joyce Children’s Health Centre (Hamilton) November was a momentous month for Hamilton Health Sciences with the grand opening of its Ron Joyce Children’s Health Centre (formerly McMaster Children’s Health Centre) in Hamilton. Strategic use of light, space and texture helps promote a sense of wellness, engagement and belonging for patients. Fully accessible, the new centre includes an outdoor wheeling track, a therapeutic playground, outdoor terraces, and physiotherapy space. Services include an autism spectrum disorder program, a child and youth mental health program, developmental pediatrics and rehabilitation, and prosthetics and orthotics services (for children and adults). The new centre can accommodate up to 70,000 patient visits annually.


24 Focus


Overcoming traditional barriers to screening and prevention By Chisholm Pothier heresa Morrisseau hadn’t really thought much about cancer in the first 59 years of her life. Growing up in Rocky Bay in an Ojibwe speaking home, health resources and education were scarce. If she was sick, she’d go see a doctor in nearby Beardmore on the one day a week the doctor came there, but in between episodes she didn’t pay it much mind. “I’m a very stubborn person,” the now 60-year-old mother of three and grandmother of nine, an Elder of Rocky Bay First Nation, says matter of factly. “I don’t go to the doctor because I have a sore leg. There’s got to be something seriously wrong with me, the leg is falling off, before I go see a doctor. I don’t want to waste anybody’s time.” But she has a daughter-in-law who might be just as stubborn. Kyla Morrisseau is involved with the Anishinaabek Cervical Cancer Screening Study (ACCSS) as a research assistant in her own community and bugged her mother-inlaw to join in until she finally relented. What she learned through that about the incidence of cervical cancer among Indigenous women and the importance of screening was a revelation. So when a lump formed on her chest, she went and checked it out. It was a serious case of myeloblastoma which has since been treated and is in remission. She’s not sure she would be alive today if she hadn’t acted when she did. She has friends who didn’t act in time. They were not so lucky. So Ms. Morrisseau has become a big booster of women in the Indigenous community, and women in general, getting information and educating themselves about the possibilities of getting cancer and the actions they can take to prevent it or detect it early enough. And that interest stems largely from a joint project led by the Thunder Bay Regional Research Institute (TBRRI) and Lakehead University to incorporate art into a research study on cervical cancer screening. Dr. Ingeborg Zehbe is a researcher at the TBRRI leading the ACCSS. She knew that Indigenous women had higher cervical cancer incidence, most likely due to the lower screening and follow-up rates, and the study is designed to address that. In thinking about how to get the message of the importance of screening across effectively, she ended up consulting Dr. Pauline Sameshima, the Canada Research Chair in Arts Integrated Studies at Lakehead University. Dr. Zehbe had integrated art into the ACCSS already to design the study pamphlet with the community women and a local artist from Gull Bay designing the study symbol – a turtle. The problem they faced is the reality Ms. Morrisseau lived for most of her life.



Dr. Ingeborg Zehbe is a researcher at the Thunder Bay Regional Research Institute leading the Anishinaabek Cervical Cancer Screening Study Research project overcomes traditional barriers to screening and prevention. First Nations women are less likely to seek out medical care until it’s absolutely necessary. And they have less access to education on health issues. Growing up, Ms. Morrisseau didn’t have easy access to health resources or information. There was no doctor or public nurse in the community. The subject didn’t get talked about in the home. In the numerous more remote communities in Northwestern Ontario the situation was probably even worse.

First Nations women in Ontario are approximately twice as likely to get cervical cancer as the mainstream population.

“There was nobody to say I’m working on health issues,” she recalls. “No one to say what the consequences of not getting these tests done are. No one to give the relevant information.” Going off reserve to get even limited access to health wasn’t particularly appealing either. Residents had had enough

bad experiences that they avoided interactions with anything that smacked of the non-aboriginal world. So it would have to be a fairly serious situation to go. “We saw the government as the bad guy,” she says. “So you kind of stayed away from the whole deal . . . we would go if we had to, but otherwise no.” Addressing these structural barriers – factors like remote geography, transportation issues and lack of adequate health resources on reserves – as well as cultural barriers stemming from the legacy of colonialism following contact with Europeans that face First Nations women like Ms. Morrisseau even today, is the goal of the ACCSS. The project’s web site states First Nations women in Ontario are approximately twice as likely to get cervical cancer as the mainstream population. Studies from an Albertan First Nations community have found women there 20 times as likely as the mainstream population to develop cervical cancer. Cervical cancer is highly preventable using Pap screening and testing for Human papillomavirus (HPV), the main risk for cervical cancer. Despite these options, according to the ACCSS web site, First Nations women endure notably higher rates of diagnosis and mortality due to cervical cancer. Thus the ACCSS project, a research

study based in Thunder Bay and involving 10 First Nations communities in Northwestern Ontario is premised on the safe assumption that if cervical cancer screening and follow-up of abnormal results is better organized in First Nations communities, the incidence of cervical cancer will go down. But Dr. Zehbe realized after conducting some pre-study focus groups that a traditional approach to education wasn’t going to work. So the goal became to find innovative educational tools to promote the screening that would see greater participation. That led Dr. Zehbe to approach Dr. Pam Wakewich, a co-investigator on the study and Director of the Centre for Rural and Northern Health Research at Lakehead University. She recommended Dr. Zehbe approach Dr. Sameshima about integrating art into the education part of the project. Dr. Sameshima came up with wool felting of styrofoam balls, the balls representing HPV —work that would be done during the education sessions in an attempt to increase dialogue and communication. This was tried as a pilot in one of the 10 partner communities and the aim was for the participants to metaphorically take charge of their own wellbeing by creating their own design through felting the HPV balls. Continued on page 25


Focus 25

screening and prevention Continued from page 24

What ensued was almost magical. At the outset, there are two sides – researchers on one side, community participants listening to them on the other. Then the balls come out, the felting begins, even as a power point plays informing the participants about cervical cancer and screening, and everyone comes together in the circle as they work with questions and discussion flowing between the researchers and community members. The line between the researchers and community members disappears as each works on their ball, chatting as they do. “The difference in the amount of back and forth dialogue between the time people were felting and the time we didn’t use felting, was phenomenal,” says Dr. Sameshima. “At the end of the felting, when all the balls were out, there was a real sense of community. We probably all have the virus in us, it’s dangerous for some, not dangerous for others, but as a group we can all care for one another.”

First Nations women are less likely to seek out medical care until it’s absolutely necessary. And they have less access to education on health issues. The study can say it has saved at least one life. Armed with the information she received at the felting session, Ms. Morrisseau sought medical attention when she had a persistent sore rib. It was attributed to a recent fall she had, was likely broken and only time would heal it. That sounded reasonable, so she went home, determined to live through the pain in the meantime. But after two weeks without the pain subsiding, she realized something had to be wrong. In the past, said her daughterin-law Kyla, she would have just continued to suffer. But with the awareness the cancer information had created, she returned to get checked out again. Testing discovered she had cancer and it was causing her bones to break. Her treatment was successful and now she says she’s fit enough to take on her interviewer in a race. But she knows what fate awaited her if she hadn’t been on top of her own health and eager to get tested. In the aftermath of the felting session, some of the other women participating who had not previously been screened went and got screened. And a roomful of women are now ambassadors for screening, talking about their experience with their friends and neighbours. Ms. Morrisseau said she visited her grandson in a supported living home where he stays and was showing him her HPV ball and telling him about the experience. All the women working at the home who listened to the story subsequently went and got screened. “The ladies go home, like I do, and talk about it,” she says. “They have a cup of tea, like I did with my sister and tell her what I went through. Actually my sister’s done a couple of tests because of what I went through.”

That cascading effect in the wake ake of the workshop is an important part of the project, says Dr. Zehbe. “The evolution is just beginning,”” says .” Ms. Morrisseau. “This is just a start.” nishiFor more information on the Anishinaabek Cervical Cancer Screening Study H visit its web site at ■ Chisholm Pothier is nt, VP Communications & Engagement, Aboriginal Affairs and Governmentt al Relations at Thunder Bay Regional Health Sciences Centre. Theresa Morrisseau


YOUR ADVANTAGE, in and out of the courtroom.


26 Nursing Pulse

Participation in World Pride festivities across Ontario, including Toronto’s Pride Parade, has become a tradition at RNAO.

A history of diversity and inclusivity The Registered Nurses’ Association of Ontario (RNAO) is celebrating its 90th anniversary during 2015. In a series of articles in its bimonthly publication, Registered Nurse Journal, the association looks back at some of its milestone moments over the past nine decades. This excerpt illustrates its work on diversity, a matter that has shaped the profession and the association’s work. By Kimberley Kearsey he Registered Nurses’ Association of Ontario (RNAO) had only just celebrated two decades of existence when black women in Canada were finally allowed to go to school for nursing. It was the late-1940s, and Jocelyn Hezekiah hadn’t yet reached her 10th birthday. She wasn’t thinking about a career in nursing…yet. Fast forward three decades and Hezekiah, who hails from Trinidad, would find herself at the helm of the provincial organization representing registered nurses, assuming the role of the association’s first president from a cultural minority. She reflects back and remarks candidly that racism was not a pressing issue for RNAO in the late 70s. “It may very well have been there, but it wasn’t on the front burner,” she recalls. In fact, it wouldn’t come to the forefront for another decade. Former public health nurse and long-time RNAO member Daphne Bailey, who (like Hezekiah) studied nursing and midwifery in the U.K., arrived in Canada in 1960. She says she was “lucky” to work as a nurse for decades without feeling the direct impact of discrimination. Originally from Jamaica, Bailey was so happy to be in the role she dreamed about as a child that she didn’t concern herself with cultural differences. “I just look at people as people,” she explains. “That interests me more than skin.” Hezekiah concurs, but acknowledges, as does Bailey, that discrimination was a reality for some of their colleagues. In the early 1990s, a group of seven black nurses at Toronto’s Northwestern General Hospital (now Humber River Regional Hospital) took their claims of discrimination and exclusion to the Ontario Human Rights Commission (OHRC). The nurses said that “…access to professional development and training, shift assignments, disciplinary actions and promotions were based on racial factors, and that (Caucasian) nurses received preferential treatment,” according to historical documentation from the Ontario Nurses Association (ONA). They also complained the hospital had refused to support them when they were abused and harassed by patients and their families. In 1994, OHRC ruled in favour of the nurses and “…the hospital agreed to pay $320,000 and to take steps to ensure a



Jocelyn Hezekiah (left) was president-elect of RNAO in this image from the 1977 annual general meeting. Maureen Powers (centre) and Irmajean Bajnok (right) were executive director and president, respectively. racism-free workplace,” according to ONA. The ruling was a turning point in discussions about racism in the health-care sector, says Rani Srivastava, who was elected to RNAO’s board of directors in 2000. And “…it was a huge catalyst for me getting involved…” in the association, she adds. When she heard then-RNAO President Kathleen MacMillan speak publicly about the case in 1994, and the need for healthcare organizations to take a closer look at their processes with an anti-racism lens, Srivastava, whose cultural background is southeast Asian, remembers being pleased that an RNAO nursing leader was touching on an issue that she was very aware of on a personal level. “I would go to RNAO meetings and… people didn’t look like me,” Srivastava says. After the OHRC decision, provincial funding was allocated to create pilot projects that would tackle issues of racism. Hospitals, including the one where Srivastava worked at the time (Wellesley Central Hospital, now closed), applied for grants and launched anti-racism projects. Srivastava, now chief of nursing and professional practice at Toronto’s Centre for Addiction and Mental Health, knew she wanted to be a part of that change. She shared that desire with other RNs who were joining the RNAO board at the same time. Joan Lesmond was one of them. Originally from St. Lucia, Lesmond became the association’s second black presi-

dent in 2002. During her tenure – and as a top priority – RNAO formalized its antiracism policy that was first drafted under MacMillan’s leadership in the late 90s. The board also worked to define what it truly means to respect diversity and to promote inclusivity. Gurjit Sangha, who was born in Canada but whose parents came from India, represented Region 6 on the board at that time, and recalls two important things about Lesmond’s legacy. The first was the anti-racism policy, which was formalized in 2002. The association committed to “…an environment where all nurses and clients are treated with dignity and respect, and where diversity is valued. “I think seeing her as leader of the organization made people think ‘how is it that RNAO can attract someone like Joan Lesmond?’” Sangha says, suggesting Lesmond’s presidency led members who may not have felt represented to think “…there must be something there that’s going to appeal to us and something important to us.” RNAO is a reflection of what is going on in the broader community, Hezekiah suggests, and people started talking openly about diversity and inclusivity at the turn of the century. Lesmond, who succumbed to cancer in 2011, was a trailblazer in this regard, and was keenly aware of the importance of having the profession of nursing reflect the diversity of the population. In an interview before taking the helm,

she said: “Above all else, my fundamental belief in the basic value of respect for all people and a willingness to learn precedes all else and is the foundation on which I will build my presidency.” She went on to lead the launch of RNAO’s Embracing Diversity Initiative, suggesting that through that work, RNAO had an opportunity “… to show leadership in a meaningful manner by… defining what diversity and inclusivity mean in practical and symbolic terms.” She called on nurses to “…own this issue, and inform it.” Acknowledging that discrimination is not only about race, RNAO began advocating against marginalization of other populations, and in particular, people who are transgender, including those who identify as transsexual. In 2007, the Rainbow Nursing Interest Group (RNIG) was formed to advance lesbian, gay, bisexual, and transgender (LGBT) inclusivity in education, research and the workplace. RNAO participates each year in festivities across the province to mark World Pride, including Toronto’s Pride Parade, and submissions to government on issues of gender equality are ongoing. In 2012, the association presented to the standing committee on social policy regarding Bill 33, Toby’s Act, which called for the right to be free from discrimination and harassment because of gender identity or gender expression. RNAO took a stand because all discrimination “…erodes health through increased risk of violence, poverty, and social exclusion, diminishes access to health care, and threatens quality work environments,” CEO Doris Grinspun told the committee. “I think it’s fantastic we’re paying attention to gender and sexual orientation… there’s lots of things that marginalize people in groups,” Srivastava says. “I think the groups you focus on change over time, but I think what you don’t want to lose sight of is the over-arching principles.” RNAO considers diversity and inclusivity in so much of its work, Grinspun says, and Srivastava agrees. “We haven’t lost H that.” ■ Kimberley Kearsey is managing editor for RNAO, the professional association representing registered nurses, nurse practitioners, and nursing students in Ontario. For more information about RNAO, visit

Evidence Matters 27

Folate: A tale of two tests By Teo Quay and Janice Mann ur bodies need folate – an essential nutrient – to develop and grow. Folate, also called vitamin B9, can’t be stored in large amounts by our bodies, so we need to get it from the foods we eat. Folate is naturally found in leafy green vegetables, root vegetables, and legumes (to mention only a few sources). A synthetic form of folate, called folic acid, can also be taken as a dietary supplement or added to common foods to ensure that we aren’t lacking this important nutrient. In fact, Canada has fortified wheat flour with folic acid since 1998, making many of the foods we eat every day such as bread, cereal, and pasta good sources of folate. Not having enough folate in your body can lead to some serious medical conditions. In one of these, called anemia, the number of red blood cells is lower than normal so your body isn’t getting as much oxygen as it should. This can make you feel tired and out of breath. For pregnant women, having enough folate is especially important to help prevent birth defects including neural tube defects affecting the brain, spine, and spinal cord; heart defects; and cleft lip and palate. Some medications such as methotrexate and some antibiotics as well as medical conditions like inflammatory bowel disease, alcohol dependency, and celiac disease can put you at a higher risk of folate deficiency.


There are very few risks to supplementing with folic acid and it likely costs significantly less than testing folate levels. If a folate deficiency is suspected, blood tests can be ordered to check folate levels. There are two different tests available. One measures the amount of folate in the serum or fluid part of your blood – called serum folate testing. A second measures the amount of folate inside your red blood cells – called red blood cell folate testing. The serum folate test is easier to perform, but the results can be influenced by your recent dietary intake of folate. Red blood cell folate testing is technically more difficult and therefore more costly, but can provide a more accurate measure of folate in your body over the long-term. If you do have a folate deficiency, it can usually be easily treated with daily folic acid supplements. The availability of two different tests makes decisions about measuring the amount of folate in your body a little more difficult. Which test should be ordered? To make things even more complicated, some

health care professionals feel that because folate and folic acid supplementation are so common in our diets, the risk of being deficient is really low and we don’t need to test folate levels at all. In this case, if a deficiency is suspected or you are at increased risk of a deficiency, they may recommend simply taking folic acid supplements without testing first. There are very few risks to supplementing with folic acid and it likely costs significantly less than testing folate levels. To help sort out this confusion about testing folate levels, the medical community turned to CADTH – an independent agency that finds, assesses, and summarizes the research on drugs, medical devices, tests, and procedures – to find out what the evidence says. When CADTH searched for the evidence on folate testing, they found 12 relevant publications – one systematic review, two non-randomized studies, and nine evidence-based guidelines. The evidence, although very limited, did not seem to show any benefit to patients when their folate levels were tested. In fact, the evidence found that testing identifies very few cases of folate deficiency and doesn’t change how folate deficiency is treated. And whether folate testing offered good value for the costs involved was unclear. In general, the guidelines did recommend folate testing for patients with health conditions that can lead to folate deficiency, but these recommendations were based mostly on expert opinion and lower quality evidence. If testing for folate deficiency, the guidelines recommended serum folate testing over red blood cell folate tests. Overall, there is little evidence to support routine folate testing in Canada. So what does all this mean for health care professionals, their patients, and the health care system? The evidence, together with very low rates of folate deficiency in Canada, indicates that testing of folate

levels may not be warranted. And in fact, some hospitals and health regions in Canada have already restricted the availability of folate testing (or eliminated it altogether). Testing may be useful for some patients, especially those who may not respond well to treatment, but it would appear that serum folate testing – the simpler and less costly test – would then be adequate. Knowing the evidence on folate testing can help with making important decisions in Canadian healthcare. In this case, limiting or eliminating folate testing, and choosing the least costly testing option for

those who are tested, could offer cost savings to the health care system without affecting the health of patients. If you would like to learn more about CADTH and the evidence it has to offer to help guide healthcare decisions in Canada, please visit, follow us on Twitter: @CADTH_ACMTS, or talk to our Liaison Officer in your region: www. H ■ Teo Quay is a Clinical Research Officer and Janice Mann is a Knowledge Mobilization Officer at CADTH.

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28 Legal Update

A legal review of 2015 By Michael Watts, Jeff Murray and David Solomon 015 has been yet another year marked by significant legal developments affecting the Canadian health care sector and, in particular, public hospitals in Ontario. This article provides a brief summary of some of these developments and the corresponding steps hospitals need to take to ensure they remain compliant with applicable laws and policies.


Significant Legal Decisions In Carter v Canada (Attorney General), 2015 SCC 5 (decided February 6, 2015) the Supreme Court unanimously declared the Criminal Code prohibitions on assisted suicide invalid to the extent that they prohibit physician-assisted death for a competent adult who clearly consents to the termination of life, and who has a grievous and irremediable medical condition that causes him or her enduring and intolerable suffering. Notably, the foregoing test does not require that a patient be terminal. The decision has major implications for end-of-life care, informed consent, and conscientious objectors, particularly where a patient is not terminal. Although the Court suspended the declaration of invalidity for 12 months to allow colleges, Parliament, and the provincial legislatures to craft a responsive legislative and regulatory framework, it is unclear whether any such framework will be in place by February 6, 2016 (or whether the Court will extend

the declaration). It has been over 25 years, for example, since the Court struck down the Criminal Code prohibitions on abortion in R v Morgentaler, [1988] 1 SCR 30, and there is still no legislation in Ontario governing abortions. Accordingly, hospitals need to be prepared to provide access to physician-assisted death (either by onsite service or by offsite referral) as well as to asses difficult cases against the test in Carter. For an in-depth analysis of the Carter decision, please visit our Health Industry Group webpage at In Hopkins v Kay, 2015 ONCA 12, the Ontario Court of Appeal ruled that a hospital can be held liable for failing to prevent unauthorized access to personal health information by an employee, even in circumstances where the Information and Privacy Commissioner of Ontario has closed his investigation. The Court rejected the argument that the Personal Health Information Protection Act, 2004 (PHIPA) is a complete code governing the liability of health information custodians. Hopkins highlights the need for hospitals to put in place clear policies and procedures, training and compliance programs, reporting mechanisms, audit structures and discipline mechanisms governing access to personal health information. In this regard, hospitals can take comfort that a recent labour arbitration ruling upheld employee termination for egregious

breaches of PHIPA and hospital privacy polices (see Ontario Nurses Association v Norfolk General Hospital, [2015] OLAA No 353). For an in-depth analysis of the Hopkins decision and the PHIPA regime, please refer to Osler’s article entitled “Ontario Court of Appeal Allows Privacy Class Action to Proceed Against Hospital” available at

Significant Legislative Developments In the aftermath of Hopkins, the Minister of Health and Long-Term Care (MOHLTC) announced the introduction of the Health Information Protection Act, 2015 (HIPA), which amends PHIPA and other statutes. Among other things, the amendments make it mandatory for health information custodians to report privacy breaches and doubles the maximum fines for offences under PHIPA. In addition, HIPA repeals and replaces the Quality of Care Information Protection Act, 2004 (QCIPA) with a 2015 version which, among other things, redefines “quality of care information” to allow for greater protection of the deliberations and records of a quality of care committee while at the same time facilitating greater disclosure of information regarding critical incidents to patients. QCIPA 2015 also provides that disclosure of personal health information to a quality of care committee is limited to no more information “than is

reasonably necessary for the purpose of the disclosure.” Accordingly, public hospitals will need to update their policies regarding privacy breach management and critical incident/quality of care reviews. Finally, in July 2015, the MOHLTC announced it was taking steps toward appointing its first Patient Ombudsman to help people who have an unresolved complaint about their care at a public health sector organization (who it anticipated would be appointed by August 31, 2015). Once appointed, the enabling provisions of the Excellent Care for All Act will be proclaimed into law. These provisions accord sweeping powers to the Patient Ombudsman to investigate and report on complaints from patients relating to care provided by a public health sector organization. Importantly, however, the Patient Ombudsman will not have the power to issue orders or investigate private care facilities such as retirement homes. The MOHLTC has indicated that “as of Sept. 1, 2015,” all public hospitals are required to have a staff member responsible for overseeing the patient relations process as well as other measures to improve patient relations, particularly to respond to inquiries from the H Patient Ombudsman. ■ Michael Watts is a Partner, Jeffrey Murray and David Solomon are Associates in the Toronto office of Osler, Hoskin & Harcourt LLP.

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Health Care Technology 29

Using mobile technology

to help patients selfmanage at home By Alexis Dobranowski he Holland Orthopaedic & Arthritic Centre has partnered with SeamlessMD to introduce a mobile app that patients can use to self-manage their recovery at home after hip or knee replacement surgery. The Holland Centre, part of Sunnybrook Health Sciences Centre, is Canada’s largest joint replacement centre, performing over 2,200 surgeries annually. Patients undergoing hip or knee replacement surgery at the Holland Centre can now download myHip&Knee, a free app to help them get ready for surgery and stay on track during recovery. So far, more than 120 patients have downloaded the app. The application provides patients with timely reminders leading up to surgery, a daily check in to track their progress (e.g. symptoms, pain levels, joint range of motion), a library of information including

Patients undergoing hip or knee replacement surgery at the Holland Centre can now download myHip&Knee, a free app to help them get ready for surgery and stay on track during recovery. “After conducting focus groups, we learned that many of our patients had access to smartphones and tablets, and



exercise videos and feedback on how to recovery safely at home. The Holland Centre will use the data to derive insights on how patients recover to help the healthcare team continuously improve the patient experience.

wanted to be engaged through mobile applications,” says Deborah Kennedy, Manager of Hip & Knee Program Development at the Holland Centre. “This led our team to pursue this additional partner in care – a mobile app for smartphone and tablet users.” “We are excited to work with SeamlessMD to expand our strategy for patient- and family-centered care and improve the patient experience and health outcomes,” says Dr. Jeffrey Gollish, an Orthopaedic Surgeon and Medical Director of the Holland Centre. “The aim is that myHip&Knee will improve patient recov-

ery by encouraging patients to complete exercises, checking in on pain levels and mobility, and advising patients when to seek more help.” “We started SeamlessMD with the mission of giving patients the best health outcomes for surgery,” says Dr. Joshua Liu, CEO of SeamlessMD. “We are excited to partner with such a forward-thinking program as the Holland Centre to improve H joint replacement care.” ■ Alexis Dobranowski works in communications at Sunnybrook Health Sciences Centre.





Paediatric programs and developments in the treatment of paediatric disorders. Specialized programs offered on an outpatient basis. Developments in the treatment of neurodegenerative disorders, traumatic brain injury. Social work programs helping patients and families AUGUST 2015 | VOLUME 28 ISSUE 9 | address the impact of illness.

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Members of the Sunnybrook Holland Centre team celebrate the launch of the myHip&Knee app.

INSIDE Safe Medication .................................12 From the CEO’s desk .........................13 Evidence Matters ............................... 14 Legal Update ...................................... 17 Nursing Pulse .....................................23

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30 Health Care Technology

Smoothing the transition of care for general

internal medicine patients By Alannah Smith n 80 year old woman is awaiting a knee replacement surgery. During her wait, she is admitted to the hospital with symptoms of congestive heart failure (CHF), however her tests come back negative and CHF is ruled out. Weeks go by and her primary care provider does not receive a discharge summary until three days before her knee replacement surgery – and the discharge summary received is inaccurate. The inaccuracy and lateness causes issues at the time of surgery and causes uncertainty with the primary care provider. Scenarios like this one are all too familiar – but this does not have to be the case. In an effort to improve the discharge process and make scenarios like this one a thing of the past, a team of clinical directors and physicians at Markham Stouffville Hospital (MSH) embarked on a journey with the Improving and Driving Excellence Across Sectors (IDEAS) program in late 2014. The outcome was PostHospital Transition of Care: From Hospital to Family Practice, a project aimed at improving the discharge process and creating a smooth transition of care for general internal medicine (GIM) patients. The aim of this project was clear: by April 2015, 75 per cent of patients discharged by a GIM physician would have a comprehensive discharge summary sent to their primary care physician within 48 hours. “The goal was to have a comprehensive, legible discharge summary on the family physicians desk (virtual or otherwise) within two days of discharge, thus achieving the broader goal of primary care engagement with the hospital as well as a more seamless transfer of care to the community for patients,” says Paul Cappuccio, Director, Mental Health Services and Family Medicine, South East York Region Health Link and Interim Director of Emergency Services at Markham Stouffville Hospital. The broader goal was to develop a better working relationship with primary care partners to improve the quality of care for patients in the hospital’s catchment area. In this context, a survey of primary care providers showed that over 95 per cent of surveyed physicians valued timely,


(L to R) Dr. Karuna Gupta, Julie Sullivan, Paul Cappuccio, Dr. Lola Oyenubi. electronic discharge summaries from the hospital. By enabling an electronic transfer of discharge summaries and implementing a 48 hour turnaround goal, patients receive better care. Primary care providers can schedule follow-up appointments in a timely manner, medication reconciliation is built into the electronic medical record (EMR) system EMR and the demand for transcription services decreases. “In order to engage primary care physicians in a timely and meaningful manner, being able to electronically transfer discharge summaries was imperative. The development and application of the IT/Health Record (EMR) system which would help achieve the ability to transmit electronic summaries was paramount to ensure a successful turnaround time,” says Julie Sullivan, Director, Medical Services at Markham Stouffville Hospital. In order to implement a project of this scope, the team relied on the expertise of a large inter-disciplinary team from across the hospital including senior leaders, physicians, nurses, and staff from information technology, pharmacy and human resources. There were also many enabling factors within the organization that needed to happen to ensure this project

For physicians working in busy hospitals, seeing past the walls of their own unit can be difficult and engaging primary care physicians has historically been a time consuming task. would not only work, but last. From figuring out how to ensure commitment to this change from within the organization, to recognizing and engaging the diverse disciplines affected by this change – getting and maintaining support from across the organization was crucial for this project to succeed. Although the influencers were from a broad group of disciplines within the organization, the most important enablers were the GIM physicians themselves. To ensure success, GIM physicians needed to transition to EMR and their behavioural change was the key to success. “In order to grow and improve, change is not only possible, but necessary. This notion is what enabled our success,” says

Dr. Lola Oyenubi, General Internist/Hospitalist. “Being able to empower the GIM physicians to be the force of change was very rewarding for everyone involved – and ultimately, our patients are benefiting directly from this change and that’s what is really important.” The IDEAS team worked tirelessly and diligently to ensure this project was not just a change, but a shift in behaviour. By including all the areas impacted by this change into the project, and by implementing this from the ground up, the results that have been observed so far have surpassed the project’s original goals. Following the implementation of the Post Hospital Transition of Care project, GIM discharge summary turnaround time has dramatically decreased by 94.6 per cent and 86.7 per cent of all discharge summaries are provided to primary care physicians within 48 hours (the original aim was 75 per cent). “Now that we have a successful model, there is no going back,” says Dr. Karuna Gupta, Family Physician. “By providing a clear goal for the discharge summary turnaround time and improving the quality of the discharge summary, we are one step closer to providing a seamless transfer of care for patients from the hospital to their family doctor.” For physicians working in busy hospitals, seeing past the walls of their own unit can be difficult and engaging primary care physicians has historically been a time consuming task. The team at MSH noticed these barriers and set out to break them down by using technology and behaviour change. This new process makes discharge summaries easier, more effective and makes getting the info to primary care providers simple and more streamlined. To ensure long-term success, this project has been accepted into MSH’s Quality Improvement Plan (QIP) and going forward, progress will be monitored quarterly. MSH is now exploring opportunities to spread the success of this initiative to other programs within the organization. To learn more about this initiative, H email ■ Alannah Smith is a Corporate Communications Specialist at Markham Stouffville Hospital.

Expanding capacity for mental health care across Ontario By Kate Richards aved Alloo is a family physician with a bustling community practice in the north end of Toronto. Over the last two decades he has seen the nature of his practice change dramatically. As people are living longer, he is seeing patients with increasingly complex and co-occurring conditions and managing physical illness that previously could have been fatal. In particular, treating patients with multiple overlapping



mental and physical illnesses is more and more common. “I’m running an entirely different practice now than I was 15 years ago,” says Dr. Alloo. “Our population is changing and we are moving away from treating acute care needs to more chronic and complex needs.” For many Ontarians, primary health care clinics are the first point of entry to the healthcare system and more than 20 per cent of all primary care visits in Ontario in-

clude mental health concerns. Frequently patients will present to a local clinic with physical health concerns then, through continued assessment, histories of trauma, sexual abuse, anxiety and severe depression begin to surface. With so many co-occuring concerns, it can be difficult to determine which condition to tackle first, and expertise is often stretched to the limit. Adding to the challenge are the long wait lists for specialized mental health care. “More

people are seeking help now for mental illness, which is great, but we’re seeing that the need for services has far outstripped the supply,” says Dr. Alloo. Amy Restoule is a social worker with Sudbury East Community Health Centre. As the only social worker serving three Sudbury-East communities, she sees the gaps in expertise and services for mental illness first hand. Continued on page 31

Health Care Technology 31

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QNovember 29–December 4, 2015 RSNA Annual Meeting 2015 McCormick Place, Chicago, United States Website: Dr. Crawford and Dr. Sockalingam participate in a weekly ECHO session.

mental health care

Continued from page 30

Similar to Dr. Alloo’s practice in Toronto, “we tend to see complex mental illness compounded with physical illness,” Amy says. High rates of anxiety, depression, posttraumatic stress disorder (PTSD) and limited local services available to support patients can make the Sudbury team feel like there aren’t enough options.

For many Ontarians, primary health care clinics are the first point of entry to the health care system and more than 20 per cent of all primary care visits in Ontario include mental health concerns. Bringing experts together A new collaborative project led by CAMH and the University of Toronto (UofT) will help address these challenges faced by primary care providers. ECHO Ontario Mental Health at CAMH and UofT is a virtual community of practice connecting 18 rural “spoke” primary care sites with mental health and addiction specialists at the Toronto-based “hub”. The Project ECHO model, developed at the University of New Mexico School of Medicine, aims to bridge academic health science centres and the frontline of community care to improve and expand clinical skills and capacity. The new ECHO at CAMH and UofT was launched on October 6 and is the first mental health-focused ECHO in Ontario, thanks to support from Ontario’s Ministry of Health and LongTerm Care. “The ECHO model uses multi-point live video conferencing to connect mental health experts at the hub to multiple primary care providers, allowing for realtime case consultation and feedback,” says Linda Mohri, Executive Director of Access and Transitions at CAMH and co-chair of ECHO Ontario Mental Health. “Through this multi-directional learning structure, ECHO Ontario at

CAMH and UofT will equip primary care providers with knowledge and support to manage complex needs within their own practices.” Dr. Allison Crawford, CAMH psychiatrist and assistant professor of psychiatry at UofT, co-chairs the weekly, two-hour ECHO sessions with Dr. Sanjeev Sockalingam, psychiatrist at the University Health Network and associate professor of psychiatry at UofT. “This is a really exciting project, with the opportunity for every health care provider at the table to learn together, which will translate into best practices that can help patients,” says Dr. Crawford, who is also head of the Northern Psychiatric Outreach Program and Telepsychiatry at CAMH. “It’s also a very patient-centered approach. Instead of sending one patient out to see multiple specialists, or where specialists may not be available, we are bringing the experts to one table and mapping out a treatment plan together.” The weekly sessions include a didactic presentation based on a curriculum validated by primary care, and anonymized case discussions by spokes. Dr. Alloo in Toronto and Amy Restoule in Sudbury are both participants in the new ECHO community, and early impressions are very positive. As an expert in the Toronto-based hub, Dr. Alloo presented the first patient case to the ECHO group and found that the recommendations helped clarify a way forward to help his patient. “There was a renewal of hope and support that I got from the session, and I felt like there were options and that we could work together to solve a problem that previously seemed intractable,” says Dr. Alloo. “With so many different experts at the table, you can feel more secure with the decisions you’re making.” Amy has also been energized by the first ECHO sessions noting that even though the case presented may not be someone in her practice, “there always something we can take back, some relatable factor that we may not have thought of,” she says. “Having ECHO to rely on – and contribute to – affords us the ability to get recommendations in a timely manner, and that is H so important for our patients.” ■ Kate Richards is a Senior Media Relations Specialist at The Centre for Addiction and Mental Health (CAMH).

QDecember 1–2, 2015 Data Analytics for Healthcare International Plaza Hotel Toronto, Ontario Website: QDecember 1, 2015 Health Canada: Financial Models and Fiscal Incentives in Health and Health Care InterContintental Toronto Centre Hotel, Ontario Website: QJanuary 26–27, 2016 12th Annual Mobile Healthcare Toronto, Ontario Website: QJanuary 28–29, 2016 Canadian Alternate level of Care Conference Toronto, Ontario Website: QJanuary 30–31, 2016 Acceptance and Commitment Therapy Workshops Emmanuel College, University of Toronto Website: QMarch 1–5, 2016 13th Annual Critical Care Conference Whistler, British Columbia Website: QApril 5–6, 2016 Together We Care OLTCA & ORCA Annual Convention and Trade Show Metro Toronto Convention Centre, Toronto Website: Q April 16–19, 2016 The Canadian Conference on Medical Education Fairmont The Queen Elizabeth, Montreal Website: Q April 17–19, 2016 Putting the Pieces Together – Collaborating for Quality Hospice Palliative Care in Ontario The Sheraton Parkway and Convention Centre, Richmond Hill Website: Q May 9–12, 2016 2016 CAHSPR Conference – Hilton Toronto, Ontario Website: Q June 5–8, 2016 eHealth Conference Vancouver, BC Website: Q June 5–7, 2016 Annual OACCAC Conference Westin Harbour Castle Hotel, Toronto Website:

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