Quality & Safety
Fraser Health Authority is committed to delivering the highest quality of care, while keeping patient safety at the forefront. In this section of the website, you will find a variety of useful links and resources relating to physician orientation and learning summaries.

Infection Control for Physicians

The incidence of Healthcare associated infection

Each year, almost 2,000 Fraser Health patients suffer the consequences of Healthcare associated infections (HAI). While even best practices cannot eliminate all cases of HAI, compliance with infection control procedures, particularly by physicians, will significantly lower the rates of facility associated infection.

Of greatest concern: C.difficile and VRE

The rates of infection in Fraser Health for C.difficile and VRE are above the national average. In the case of MSRA, annual rates have been maintained below the national average, however not consistently so month to month. A concerted effort is needed to reduce infection rates.

OTHERS WILL FOLLOW

While infection control is everyone’s responsibility, physicians are viewed as medical leaders and role models who wield a great deal of influence over other health care professionals and clinic staff. Following best practices personally will have a significant positive outcome for your team and your patients.

PROPER HAND HYGIENE IS #1 FOR PREVENTING INFECTION

  • Clean your hands before and after each patient contact, and before and after using gloves even with the same patient. Gloves are never an acceptable substitute for hand cleaning.
  • IF your hands are visibly soiled, or IF you are in contact with a patient recently or currently on antibiotics (C. difficile risk), wash your hands with soap and water.
  • In all other situations, alcohol rub is more effective.
  • However, in both cases, you must use proper technique ensuring that the palm, dorsum, fingers, finger tips, nails, and thumbs on both hands as well as both wrists are thoroughly washed or covered with alcohol rub. LEARN MORE
  • Be aware of potential sources of contamination after cleaning and prior to patient contact, such as clothing, stethoscopes, bed rails, exam tables, etc.

CLEAN PERSONAL EQUIPMENT AND INSPECT FACILITY EQUIPMENT

  • Stethoscopes, otoscopes, ophthalmoscopes, pens, patient charts, computer keyboards and computer mice are all potential sources of contamination.
  • Make it a habit to clean all tools you carry with you (e.g. stethoscope, pen) before and after patient contact.
  • Visually inspect all common use and facility supplied tools, materials, and equipment before use, and replace any that you suspect may not have been properly sanitized.

ENSURE PROPER CLEANING OF OFFICES AND CLINICS

  • Standard office cleaning practices are not sufficient for any space used by patients.
  • Ensure that janitorial staff use appropriate cleaning solutions and practices.
  • Offices, office equipment, and examination rooms need to be cleaned daily.
  • Exam tables should include a paper roll with a full section of paper changed between patients; exam tables should also be thoroughly cleaned daily.
  • For more information you can download the BC Centre for Disease Control’s “Guide to Infection Prevention and Control in the Physician’s Office.”

GASTROINTESTINAL AND RESPIRATORY INFECTION OUTBREAK MANAGEMENT

  • Physicians who work within or see patients in facilities are to work collaboratively with MHO/EHO/ICP and Facility Managers to ensure best practices are used for the prevention and control of outbreaks.
  • This includes early recognition of clusters of GI infections, diligent use and promotion of hand hygiene, early recognition of possible outbreaks and timely implementation of control strategies.
  • Physicians who suspect they have acquired a GI or RI should leave the workplace immediately, remain at home for 48 hours after symptoms have disappeared, and take precautions when they return to work.
  • It is also extremely helpful for physicians who have clinic patients with suspected or confirmed GI or RI, to advise these patients not to visit hospitals or other care facilities for a week after symptoms have resolved.
  • Physicians who work daily or frequently within facilities may wish to review more complete information on outbreak management.

OR Safety, Patient Safety and Learning Summaries

OR Safety

Culture of Safety in the Surgical Suite

A new culture of safety in the operating rooms has developed over the last 5 years. The aim is to improve safety for patients and staff. In adopting this new culture, Fraser Health has established the following components:

1. Site Marking 

Where surgery is to be performed on one side of the body (inguinal hernia surgery, amputation), site marking is done by the surgeon in the preoperative holding area.

2. Surgical Safety Checklist 

The FHA Surgical Safety Checklist is based on WHO checklist. All FH operating rooms have the Checklist mounted on the wall. Surgeons and operating room personnel are expected to conduct all 3 phases for each operation:

  • Pre-induction
  • Pre-incision
  • Debriefing

Combined with the surgical pause and site marking, the checklist has been shown to reduce medical errors and improve engagement and morale of the nursing staff.

3. Patient Warming 

To reduce the risk of surgical site infection efforts are directed at keeping the patient warm before, during, and after surgery. Patients should arrive in the PACU with a core temperature of at least 36 degrees.

4. Neutral Zone 

The frequency of penetrating injuries suffered by nurses and surgeons can be reduced by using a designated area (neutral zone) between the scrub nurse and the surgeon for exchange of sharp instruments. Contact your Head of Department (local) or Regional Division Head for information.

Blood and Body Fluids

Assistance for Medical Staff Exposed to Blood or Body Fluids

Blood and Body Fluids

Policy, protocol, and a team of Workplace Health professionals are in place to provide assistance to medical staff who have been exposed to blood or body fluids.

Fraser Health provides immediate clinical remediation and ongoing follow up clinical and process support to any member of the medical staff, including physicians, midwives, and dentists. Letting the experts guide you will keep you on a well-established path to peace of mind, and allow you to avoid frustrating tangles with confidentiality issues.

To access these services and ensure that policies and protocols are followed, it is essential that you take the steps outlined below. For ease of reference, we suggest you print the Blood and Body Fluid Exposure Journal for Medical Staff (BBF Journal) - a handy reference document to get the process started right, and make note of instructions and information provided to you.

SEE DETAILED INSTRUCTIONS BELOW:

Go to Emergency as soon as possible and absolutely within an hour of the exposure The immediacy is important for several reasons: 

  • A baseline blood test is needed to establish your health status at the time of exposure. If you do contract an illness, clearly linking it to the exposure incident will help with any future claims or benefits entitlement.
  • The ability to assess the subject patient can diminish rapidly. If they leave the site for whatever reason, it may be impossible to locate and test them within an appropriate timeframe.
  • If the exposure has the potential to be high-risk, such as HIV, antiretroviral medications needs to be administered within two hours of exposure.
  • Your presence in Emergency starts the Workplace Health tracking process – the lab requisition form will have a case number on it that ensures that Workplace Health gets a copy of the test results.

Call Workplace Health at 1-866-922-9464

  • This only takes a few minutes and sets all of the follow up systems into motion. Dial 1-866-922-9464 and follow the prompts.
  • The Call Centre is staffed weekdays between 0700 and 1700 and you can leave a voice mail message at any time. Be sure to provide both your name and contact phone number for a call back.
  • An Occupational Health Nurse will explain everything you need to do, and how they will help you monitor and remediate.

File a report with WorkSafe BC

  • As “independents,” all medical staff (with rare exception) are required by BC law to establish and maintain coverage with WorkSafe BC. This means you must also report all incidents.
  • While Fraser Health will provide any prophylactic treatment indicated, should you become ill and/or unable to work, you may be entitled to WorkSafe BC insurance benefits.
  • Call WorkSafe BC at 1-888-967-5377 for more information.

Follow instructions given

At each of the above encounters, you’ll be given instructions, and there may be a few complexities.

  • If you, the person exposed, are the MRP for the patient who was the source of the exposure, you have two roles to play – one being the patient yourself, and the other being the MRP for the source patient.
  • As the MRP, you may be the one who needs to get informed consent from the patient to draw and test their blood, review the results, and if an illness is identified, advise and counsel the patient.
  • Similarly, in the case of WorkSafe BC you are likely the employer and the employee, so you may need to submit two reports.
Steps

Step 1 - Go to Emergency as soon as possible and absolutely within an hour of the exposure

Step 2 - Call Workplace Health at 1-866-922-9464 weekdays between 0700 and 1700, or leave a message

Step 3 - Call WorkSafe BC at 1-888-967-5377

Step 4 - Follow instructions from Emergency, Workplace Health and WorkSafe BC

Medication Reconciliation

  • Medication reconciliation is a formal, systematic process in which healthcare professionals partner with patients to ensure accurate and complete transfer of medication information at transitions of care.
  • Medication Reconciliation is based on the premise that "An up-to-date and accurate medication list is essential to safe prescribing in any setting".1
  • It is an Accreditation Canada ROP (required organizational practice).2
  • Research indicates that over 50% of patients have at least one medication discrepancy upon admission to hospital, with many discrepancies carrying the potential to cause adverse health effects.4,6
  • Over half of medication errors occur at the interfaces of care.3

For information regarding implementation of medication reconciliation initiatives at Fraser Health, contact the Fraser Health MedRec Facilitator Team:

Angela Wong: angela.wong@fraserhealth.ca

Jennifer West: jennifer.west@fraserhealth.ca

 

1. Safer Healthcare Now! Getting Started Kit: Medication Reconciliation version 3.0

2. Accreditation Canada Required Organizations Practices 2013

3. Rozich JD, Resar RK. Medication Safety: One Organization’s Approach to the Challenge. J Clin Outcomes Manage 2001; 8(10):27-34

4. Cornish P.L., et al. Unintended medication discrepancies at the time of hospital admission. Arch Intern Med. 2005; 16: 414-429.

5. World Health Organization. Assuring Medication Accuracy at Transitions of Care; Medication Reconciliation. Patient Safety Solutions, Volume 1, Solution 6, May 2007

Related Links
  • Medication Reconciliation Sharepoint Site
  • CMPA Position on Medication Reconciliation

QIPS Physician Orientation

QIPS

These education modules provide an initial introduction to the concepts of Quality Improvement and Patient Safety (QIPS) for new Fraser Health Physicians/new Fraser Health Employees. They are intended to foster personal behaviours that support Fraser Health’s quality and safety culture and improvement initiatives.

At the completion of the modules, you will be able to:

  • access the Fraser Health processes that help you to react when patient harm occurs
  • describe the reasons for healthcare’s emphasis on quality and patient safety strategies and creation of a patient safety culture
  • support the mechanisms Fraser Health is using to improve patient outcomes, foster a culture of quality and patient safety, and prevent patient harm.
Feedback

Please let us know what you think of your QIPS Orientation by completing our brief online survey here:

QIPS Physician Orientation Survey

Modules

Module 1:  Introduction to Quality & Patient Safety

Module 2:  Improving Outcomes & Preventing Harm

Module 3:  What to Do When Harm Occurs

Module 4:  Making Improvements

Module 1: Introduction to Quality & Patient Safety

Quality in Healthcare - Everyone's Business

Quality is…

“Meeting the needs and exceeding the expectations of those we serve; delivering all and only the care that the patient and the family needs.” - Institute for Healthcare Improvement

"The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge." - Institute of Medicine

Welcome to Fraser Health. You are joining a work environment that values the quality of care and service we provide to our patients, residents, clients and their families, and continually strives to make improvements.

The patient, resident and client must always be the centre of our concern; recognition of their experience, and their perceptions of the quality they receive, are fundamental to improving what we do for them.

For the purposes of these online modules, ‘patient’ refers collectively to ‘patient, client and resident’.

The Fraser Health Board expects all staff, physicians and volunteers to integrate quality improvement and patient safety principles into every day health care and service delivery.

Required Review - Patients, Clients, and Residents Safety Policy (PDF)

WHAT IF:

  • What if patients were as safe in our care as they are at home (safety)?
  • What if all care was based on best-known science (effectiveness)?
  • What if patient values helped guide all clinical decisions (patient-centredness)?
  • What if waiting was not a normal part of getting and giving care (timeliness)?
  • What if we never wasted supplies, equipment, time, energy or ideas (efficiency)?
  • What if care did not vary in quality because of personal characteristics (equity)?
  • What if all health care workers loved their jobs (workforce vitality)?
  • What if all health care students learned that quality improvement is their responsibility (professional education)?

Dr. Don Berwick, CEO, Institute for Healthcare Improvement

Some simple questions to ask yourself:

1. HOW WELL DO WE KNOW THOSE WE SERVE?

  • Who are our patients?
  • How do we know what they want, need and prefer?
  • What are their perceptions of the service they receive?

2. HOW WELL DO WE KNOW OUR WORK PROCESSES?

  • Are we doing the right things?
  • Are we doing things right?
  • How safe are patients in our system?
  • How do we know?
  • How can we be certain that we do things right the first time, every time?

3. HOW DO WE CONTINUALLY IMPROVE OUR OUTCOMES?

  • Do we have a systematic process for improvements?
  • Do we have accountability for improvements?
  • How do we know we are making a difference?
  • Do we promote leadership by example to foster change?
  • Do we learn from other industries?
  • Do we foster sustainability and spread of learnings and innovation?

All improvement is change

All change is not improvement

Medical Errors account for more deaths than accidents and AIDS combined - Professor James Reason

The first step to a safer healthcare system is to acknowledge that the current system poses many risks that are preventable. Patients enter the health care system for care, but sometimes they are harmed in ways unrelated to their original condition or illness. For example, a patient might acquire an infection or fall while in hospital. It is estimated that approximately 3% of Canadian inpatients experience one or more preventable events. While most patients recover, they often experience complications and their length of stay is longer; a small percentage of patients die or have permanent disability. Fraser Health is estimated to have 435 preventable deaths annually in acute care (Canadian Adverse Events Study, 2004).

Managing Patient Safety – James Reason

The culture of safety “…that exists in most health care organizations is weak compared to other high risk, complex businesses such as the airline, petroleum and nuclear power industries.” Most airline pilots believe they make mistakes, so the airline industry designs its equipment and processes to mitigate these. In healthcare, only 30% of providers believe they make mistakes. (Laura Adams, Faculty, Institute for Healthcare Improvement, 2005 and IHI Online Learning Program Module, Q101, 2010) Fraser Health is committed to reducing the likelihood of harmful events and designing systems of care to be as safe and reliable as possible. No matter what role you have in health care, patient safety is everyone’s responsibility.

When a process has:

the probability that every person completes that one step, every time is:

1 step 95%
25 steps Falls to 28%
100 steps Falls to 0.6%

- Laura Adams, Faculty, Institute for Healthcare Improvement, 2005

Health care is complex. If we want to ensure reliable practices in healthcare, we need to simplify the number and complexity of the steps in the care we deliver. A stable process in health care typically is 40% to 70% reliable. Other high-risk, complex industries strive for 99% and higher.

Healthcare needs a range of strategies to improve reliability:

  • information
  • education
  • rules and double checking
  • checklists protocols and pre-printed orders
  • automation and computerization and
  • forcing functions which do not allow the incorrect action to be taken (E.g. dosing ranges for medications delivered by infusion pumps can be pre-programmed so that a harmful dose can not be delivered; oxygen and medical air hoses that attach to anaesthetic machines are fitted with different coupling joints so they can not be mixed up).

It is critical to understand what matters most to our patients, and to appreciate their health care experience. In honouring this principle and demonstrating our Values of ‘Respect, Caring and Trust’, Fraser Health continuously seeks their feedback in order to:

  • challenge the assumptions we tend to make as healthcare providers; for example, clinicians may believe they have done a good job in meeting the patient’s needs for treatment or pain management, but of equal importance to patients is information and emotional support
  • identify our strengths and areas for improvement
  • understand the impact of service changes on patients
  • incorporate the patient’s experience in improvements

Fraser Health obtains ongoing and periodic feedback from patients through:

  • complaints and compliments
  • patient experience surveys (national, provincial, regional, program, area)
  • patient councils and advisory committees, and
  • interviews and focus groups to discuss specific topics.

The BC Ministry of Health views patient feedback as essential – it requires all Health Authorities to conduct ongoing BC Patient Experience Surveys, in various sectors, such as acute care, residential care and emergency services.

Fraser Health has many policies, processes and protocols that reflect a valued, respectful relationship with our patients, such as consent for health care, complaint management, privacy policies, and disclosure.

You can do your part by:

Keeping 'patients first': Putting yourself into your patient’s shoes and listening to his/her stories keeps us focused on how patients experience our relationship with them.

Taking pride in what you do: “The kind of pride I’m talking about is not the arrogant puffed-up kind: it’s just the whole idea of caring – fiercely caring.” (Red Aurbach, Professional Basketball Coach).

“Speaking Up”: Be alert to the potential for harm. ‘Looking’ does not always mean ‘Seeing’ – ask yourself what you might be missing. Question and report unsafe practices. Discuss these openly so they can be addressed promptly – you may save someone’s life or prevent them from being harmed in our care. Identify opportunities to improve - sometimes the small things can make a big difference to the quality and safety of care. Share your improvement ideas with your team - every idea counts.

Meeting standards and increasing reliability: Make yourself aware of the standards and processes of care for your practice or area, and commit to consistently meeting these.

Fostering patient self responsibility: Provide the education and support to enable patients to assume responsibility for their well-being.

Holding yourself accountable: What will you do to become more aware and improve patient safety in your office or work setting?

Module 2: Improving Outcomes & Preventing Harm

Evidence shows the administration of prophylactic antibiotics within 60 minutes of surgery results in fewer post surgical infections.

Research has confirmed the appropriate and effective care for patients with certain conditions, in order to impact health outcomes. Yet, such evidence-based care often is not well integrated into daily care. There exists a gap in what we know and what we do.

For example, the Canadian Diabetes Association has established guidelines for pressure control less than 130/80 mmHg and A1C less than or equal to 7.0% (Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada). In general, health care is not able to attain this consistently for even 80% of patients, let alone reach 99% and higher, the level attained by highly reliable organizations in other industries.

In many instances practitioners genuinely believe they are providing evidence-based care for most of their patients. Until it is measured, practitioners are often unaware of the gap between what we know should be in place and what is actually in place. For example, many practitioners expect PharmaNet, which is a record of prescriptions filled, to list the medications an individual is regularly taking, so that a medication history need not be verified. At one Fraser Health site, staff discovered PharmaNet was only 30% accurate in outlining what medications patients were regularly taking (Bruchet, Davidson, Buchkowsky, 2006). Data collection helps inform decision making i.e. patient safety indicators, performance scorecards.

You play an important role in implementing evidence-based practice, through:

Risk Assessment to identify risks and mitigate risks before incidents occur or a patient is harmed.

Standardization and Integration of care processes across programs, sectors and sites i.e. Care Policies, Care Protocols, Care Paths or Care Guidelines such as: prophylactic antibiotics to prevent surgical infections, hand hygiene guidelines, limited access to concentrated medications, diabetes protocols, stroke protocols, least restraint policies, Code Yellow, safety checklists.

Pre-approved Order Sets which outline the medical orders to support timely interdisciplinary management for a given diagnosis, high volume or high risk situation, in order to reduce practitioner variation and standardize care e.g. post-surgical procedures, emergency care for cardiac patients, weaning from ventilator care.

Reduction of waste and inefficiencies

Identification of successful innovations and spread elsewhere.

In today’s complex healthcare industry, safety, or patient harm, is of particular concern. Fraser Health is working in alignment with a wide variety of organizations (Safer Healthcare Now!, Institute of Safe Medication Practices - Canada, Canadian Patient Safety Institute, Accreditation Canada, BC Patient Safety and Quality Council) to focus on the following themes:

  • Culture of Safety
  • Infection Control
  • Medication Safety
  • Safer Systems for Patient Care
Maturity of Safety Culture Characteristics
Level 1 Why waste our time on safety?
Level 2 We do something when we have an incident

Level 3

We have systems in place to manage all like risks
Level 4 We are always on the alert for risks that might emerge
Level 5 Risk management is an integral part of everything we do

- Adapted from The Manchester Patient Safety Framework (MaPSaF ) Kirk et al, QSHC, 2007

Every workplace generates its own culture of quality and safety - shared ways of thinking and behaving that lead to ‘norms’ for that setting.

A desirable culture of safety occurs when: 

  • No patient is harmed due to their interaction with health care;
  • No family experiences the pain and frustration of caring for a loved one who is harmed;
  • The organization acknowledges the risk and error-prone nature of health care, promotes open disclosure and fosters reporting, open communication and learning from adverse events in a just and trusting environment;
  • No provider thinks that reporting an adverse event will compromise their career;
  • Health care providers assume shared accountability with the organization to actively seek potentially harmful situations and take action to address these before harm occurs.

(Adapted from CPSI, Building the Foundation for a Safer Health System, Strategic Business Plan 2004/05to 2007/08 and BC Patient Safety and Quality Council website statement, 2010)

Fraser Health has a number of mechanisms to foster a culture of safety, including its integrated approach to risk management. Take a moment to think about the characteristics of the culture in your office practice or work setting.

Required Review - FHA Integrated Risk Management Policy (PDF)

“Moving from a culture of safety to inculcating safety as a core value of who people are within the organization…requires behavioral and cultural changes. Patient safety goals are not recited from a card each year, but become intrinsic to what everyone within the organization does. Not only do they own it and question it, they demand it from their co-workers, as well.”

- Interview with Dr. Daniel Salinas, Senior Vice President and Chief Medical Officer, Children's Healthcare of Atlanta, January 2010, Zero is a Real Number: The Children's Journey to Excellence in Paediatric Quality Outcomes, National Initiative for Children’s Healthcare Quality Forum

Embedding a culture of safety into daily work is essential to supporting staff and contributing to a safe environment for our patients. Each of us contributes to the culture by applying patient safety knowledge, skills and attitudes to our daily work (CPSI Background document to The Safety Competencies, Aug. 2009).

Engaging all members of the healthcare team as valuable sources for system improvement when patient harm occurs is pivotal to creating a culture of quality and safety.

Many patient safety events occur due to a chain of events; a series of individual system failures, each of which might not be significant, but when they are not caught before they reach the patient might align to cause an adverse effect.

Many patient safety events occur due to a chain of events. If the event results in patient harm it is considered an ‘adverse event’; if it does not, it is considered a ‘near miss’. An adverse event can happen anytime, to anyone. If you happen to be at the end of the chain, it can happen to you.

Fraser Health acknowledges this, and is actively involved in creating a ‘culture of safety’:

  • improving the system that people work in
  • creating an environment that is both just and trusting when reporting and reviewing harmful events, and
  • shifting from the traditional ‘blame and shame’ approach to harm (‘who did this and why did they do it?’) to a learning approach (‘what conditions were present that made it possible for harm to occur?’).

You have an important role to play:

  • Expect that harm might occur and identify potentially harmful situations in the system before harm does occur (‘near misses’ and ‘good catches’).
  • Attend to the little problems to prevent a more significant problem further down the chain.
  • Identify ways to mitigate errors before they reach the patient or result in patient harm (keep antidotes close at hand, standardize processes, train via simulation, control access to high-risk medications, etc.).
  • Support your co-workers and avoid blame – seek to understand the system causes for the harm.
  • Simplify and strengthen your communication; avoid multiple entries for communication, clearly communicate information at hand-offs (shift changes and on transfers), do not use confusing or unsafe abbreviations.
  • Cooperate with other clinicians – it’s in the patient’s best interest.
  • Avoid reliance on memory and ‘trying harder’ – create resilience in the system through the use of checklists, simple protocols, double-checks for high risk activities.
  • Participate in improvements to care.

If you are interested in viewing the related videos "Beyond Blame" or "Delivering Patient Safety", contact Quality Improvement and Patient Safety at 604-535-4500 extension 757755.

When harm occurs or a complaint is expressed, we need to listen and support the patient, family and practitioners involved, and take steps to understand the patient’s experience. As a health care system, we need to report, study and learn from patient harm when it occurs, in order to make the healthcare system safer.

You can do your part:

Partner with patients : encourage and listen to your patients’ stories; include patient experiences when planning improvements

Hold regular team safety huddles and conversations that focus on barriers to patient safety in the care delivery setting;

Report harm or ‘near-misses’ so that concerns can be followed-up for an individual patient, and the system causes of harm and near-misses can be reviewed and trends identified;

Physicians - Patient Safety Learning Summaries and Morbidity and Mortality Rounds provide a rich source of information.

See Module ‘ What To Do When Harm Occurs .’

Patient outcomes are highly dependent on safe, collaborative, patient-centred team practices. Effective teamwork and communication are essential for preventing things from going wrong. Patients are vulnerable especially during transition points in their care (shift changes, transfers between levels of care, etc.) and due to communication gaps or multiple entries causing confusion. Many patient/family complaints are due to ineffective communication.

What are the characteristics of strong, high performing interdisciplinary teams?

  • They view their work as serving patients’ needs.
  • They assist patients to engage in decision-making and appropriately direct their own care.
  • They commit to shared objectives, clear roles and responsibilities, and interdependent decision-making. To ensure continuity of care, they effectively communicate pertinent patient information across teams and, when necessary, across organizations.

(Adapted from CPSI Safety Competencies Framework, 2009)

On average, it takes 133 staff members to care for one acute care patient. The complexity of your working environment makes it essential to work and communicate cooperatively as teams. Effective communication, both within teams and between the healthcare team and patients, is founded on trust, caring and respect. Key elements are the use of diplomacy and tact, as well as respect for the wisdom patients and providers bring to health care. Disrespectful communication is detrimental to everyone, whether you receive it or witness it. Fraser Health has developed the “Keep it Real” program to assist staff in creating effective relationships.

S

 

Situation
A concise statement of the problem

What is going on now?

B

 

Background
Brief information related to the situation
What has happened? 

A

 

Assessment
Analysis and consideration of options
What you found / think is going on? 

R

 

Recommendation
Request / recommend action
What do you want done? 

S ituation, B ackground, A ssessment, R ecommendation

SBAR is a concise communication technique to increase clarity, enhance communication and foster positive relationships amongst health care providers and with patients and families.

CHAT is a similar approach ( C urrent Condition, H istory, A ssessment, and T reatment).

Leadership Walkabouts and Safety Huddles are unit-based opportunities to discuss patient safety concerns in a supportive environment. They help to identify issues early, before problems become bigger and before they cause harm to patients. Please make a note now to ask your Medical Director or Supervisor about how this is done in your area.

Fraser Health regularly uses a variety of industry and professional standards, such as:

  • General healthcare standards including minimal standards for patient safety - Accreditation Canada
  • Medication Safety - Institute for Safe Medication Practices (ISMP - Canada)
  • Hand Hygiene – Canadian Centre for Disease Control
  • Medical Imaging and Laboratory standards - Diagnostic Accreditation Program
  • International Organization for Standardization (ISO) standards.

Staff are expected to know the standards of care for their area and for their profession. Ask your Supervisor or Medical Director for more information.

Two key areas of risk for patients are acquired infections and medication safety. Standards for medication safety focus on:

  • clear labelling
  • controlled access to and protocols for high risk medications
  • clear communication patient responsibility for knowing which medications are taken and how.

GET A COPY:

Patient poster for your practice – What’s on Your Medication List?

Ask Me – template for patient personal medication list (available in English, Chinese, French, Punjabi)

All staff, physicians and volunteers are expected to do your part to reduce the rate of infection and keep patients safe by performing regular Hand Hygiene:

  • Before touching a patient
  • Before clean/aseptic procedures
  • After a procedure or body fluid exposure risk
  • After touching a patient / patient’s environment
  • Before and after glove use.

A. Alcohol Based Hand Rub (ABHR):

  • Is quicker than using soap and water
  • Is more accessible than soap and water as is not dependent on sink location
  • Provides emollients that reduce skin irritation
  • Is effective in reducing organisms on hands.

Correct technigue for ABHR:

  • Apply a loonie size amount of ABHR in the palm of dry hands
  • Spread the ABHR to cover all surfaces of both hands, including web spaces, thumbs, wrists, and the back of the hands
  • Rub nail beds against the opposite palm
  • Rub hands together for 15-20 seconds until dry.

B. Soap and Water is required:

  • When hands are visibly soiled
  • When caring for patients with diarrhea
  • After 5 to 6 applications of an alcohol based hand rub to remove residual emollients.

Correct technigue for Hand Hygiene with Soap and Water:

  • Wet hands with water
  • Apply an adequate amount of appropriate soap
  • Use friction to wash all surfaces of both hands, including web spaces, thumbs, wrists, and the back of the hands
  • Rub nail beds against the opposite palm
  • Wash for 15-20 seconds
  • Rinse thoroughly with a steady flow of warm water
  • Dry hands with clean paper towels
  • Use paper towels to turn off taps
  • Discard paper towel.

Use Routine Practices to reduce the rate of infections:

  • Gloves:for contact with body fluids, mucous membranes and non-intact skin
  • Facial protection (mask & protective eyewear): when spraying of body fluids is likely or for providing care for patients with respiratory symptoms
  • Gown: worn when contamination of clothing is possible

Use other mechanisms to reduce the rate of infection:

  • Antibiotic stewardship
  • Environmental cleaning and housekeeping services
  • Appropriate use of Personal Protective Equipment (PPE) and isolation precautions
  • Reprocessing standards and guidelines
  • Surveillance reports and trends for infection rates
  • Audits and feedback reports – hand hygiene, reprocessing, bed pans cleaning practices, etc.
  • Bed accommodation algorithm
  • Construction/renovation planning and support
  • Mandatory reporting of communicable disease to Public Health.

For more information: Infection Prevention and Control Practitioners 604 587-4455 

Module 3: What to Do When Harm Occurs

A story of a health system failure and hope for the future. Esther was a vibrant woman who entered Fraser Health for elective surgery. Despite her best attempts to communicate her risk factors, the system’s gaps, in design, communication and assessment of an elderly individual, resulted in a chain of small system failures and her subsequent death.

Unfortunately, on occasion a patient does have a complaint or experiences harm unrelated to the natural progression of the disease or condition.

When this occurs, Fraser Health’s first priority is to ensure no further immediate harm occurs, as well as support the patient, their family and the staff involved. Then, it is critical for physicians, staff and volunteers to report patient safety events (harm and near-misses) and complaints as promptly as possible, in order to:

  • manage the situation in a timely way,
  • determine whether the harm is preventable and
  • identify issues and solutions in order to prevent their recurrence.

You are expected to:

  • report Complaints and Patient Safety Events as they occur (see next topic,"Reporting Harm")
  • participate in review follow-up if required to do so by your Medical Director or Supervisor.

FOR MORE INFORMATION:

Patient Care Quality Office
32900 Marshall Road, Abbotsford, BC, V2S 0C2
Toll free: 1-877-880-8823
Fax: 604-854-2120
Email: pcqoffice@fraserhealth.ca 

Quality Improvement and Patient Safety Consultants 
604-587-4633

Disclosure is “the process by which an adverse event is communicated to the patient by healthcare providers”

- Canadian Disclosure Guidelines, Canadian Patient Safety Institute, 2008

Disclosure of harm facilitates open, honest communication with our patients and families when something goes wrong. Transparent discussion enables the health care team to meet the patient’s immediate care needs as well as support the physical and emotional healing related to the adverse event. Disclosure addresses a range of events from ‘near harm’ to ‘actual harm’.

Required Review

Fraser Health Disclosure Policy (PDF)

Physicians - Communicating With Your Patient About Harm – Disclosure of Adverse Events, Canadian Medical Protective Association, 2008 

BCPSQC Pamphlet: Conversations when things go wrong/Information for Patients (PDF)

Fraser Health values complaints as ‘gifts’ to provide insight into the harm patients and their families experience due to unmet expectations. This sharing of concerns provides perspective to focus our improvements as well as improve relationships between patients and the health care team. Complaints cause us to challenge the assumptions we tend to make as healthcare providers regarding the issues of significant concern to our patients and their families.

All staff, physicians and volunteers are expected to report and address patient complaints when these occur, so that the issue is resolved as soon as possible for that person:

  • Staff and volunteers - report through your Manager, for local resolution, and then to the Patient Care Quality Office.
  • Physicians - report through your Program Medical Director.

The BC Ministry of Health requires each Health Authority to provide a Patient Care Quality Office for patients to voice the concerns that can not be resolved at the point of care:

Patient Care Quality Office
32900 Marshall Road, Abbotsford, BC, V2S 0C2
Toll free: 1-877-880-8823
Fax: 604-854-2120
Email: pcqoffice@fraserhealth.ca

Click here to download poster for your office

Required Review

Complaints Management Policy (PDF)

All physicians, staff and volunteers are expected to report patient harm or near-misses (patient safety events) that occur in a Fraser Health site or service, using one of the two established systems (accessible only through the Fraser Health intranet):

  • Patient Safety Learning System (PSLS) – a web-based mechanism for reporting events and near misses (available in all acute care sites – April 2010)
  • ENCON – an alternate mechanism for reporting events used in parts of the health region which do not have access to PSLS (currently being phased out as PSLS is implemented).

Reporting provides the opportunity to learn from these events, identify trends and determine priorities for improvements, through Patient Safety Event Aggregate Reviews, Physician Patient Safety Learning Summaries and Morbidity and Mortality Rounds.

FOR MORE INFORMATION:

Quality Improvement and Patient Safety Consultants 
604-587-4633 

Required Review

Patient Safety Event Management Policy (PDF)

Section 51 and Quality of Care Reviews - An Overview

Module 4: Making Improvements

"Every system is perfectly designed to achieve the results it achieves...we can put competent providers into a (problematic) system, and the system will win every time... Therefore, if you want new levels of performance, you must change how the system works.”

- Institute for Healthcare Improvement,CEO, Dr. Donald Berwick

1. Improvement focuses on closing the gap between:

  • what we know (the scientific evidence and what we know about our patients) and
  • what we do - what practices actually occur and how much inappropriate variation and practitioner preference occurs.

2. In order to make changes, you need to create the will and test ideas that will embed and sustain the desired change in daily routines.

3. Quality Improvement requires a systematic approach to plan the strategy and measurable goal, test ideas, gather data and develop strategies to sustain and spread the learnings. The team should include a triad of champions: clinical experts, operational leaders and process experts.

4. Every change has both a social and technical aspect. “Technical performance depends on the knowledge and judgement used in arriving at the appropriate strategies of care and on skill in implementing those strategies. The goodness of technical performance is judged in comparison with the best in practice…known or believed to produce the greatest improvement in health…the interpersonal process is the vehicle by which technical care is implemented and on which its success depends. Therefore, the management of the interpersonal process is to a large degree tailored to the achievement of success in technical care.” (Dr. Avedis Donabedian, 1988)

Whenever you have an improvement idea, discuss it with your colleagues or Director/Manager/Supervisor. The ‘ Model for Improvement ’ (Institute for Healthcare Improvement) is a helpful tool.

FOR MORE INFORMATION:

Quality Improvement and Patient Safety Consultants
604-587-4633

  • Maintain your focus on the patient; listen to their stories and experiences.
  • Base changes on evidence and data; confirm what you know and what you don’t know.
  • Involve providers of care as the expert clinicians.
  • Assess the potential for harm.
  • Be clear about the outcome you want to achieve and how the changes you make in processes (the way you do things) and resources (staff, equipment, budget, supplies, etc.) will affect this. If you want a certain outcome, ask yourself what processes will support it? If you want to put a certain process into place, ask yourself what resources are needed?
  • Set an ambitious Aim with clear, measurable targets for performance – what is in the best interests of your patient? A clear Aim will shape provider practices.
  • Health care is complex. Testing is almost always needed prior to implementation.
  • Measure at two levels. As you test, use simple measures to assess whether your efforts are moving you in the right direction toward your Aim. Also measure the impact – whether you are achieving your Aim.
  • Look for ways to increase the reliability of your process; standardize your approach and reduce variation in practices. Remove practitioner preference as the key reason for a change, or the reason to continue an existing process.
  • Consider how humans work in their environment (science of human factors).
  • Keep it simple – simplify processes and follow simple rules.
  • Remove waste and inefficiencies.

FOR MORE INFORMATION:

Quality Improvement and Patient
604-587-4633

BC Medical Quality Initiative (BC MQI)

The BC Medical Quality Initiative (BC MQI) is a provincial collaborating committee with representatives from the health authorities, the College of Physicians and Surgeons of BC, the Ministry of Health, the BC Patient Safety & Quality Council and the BC Medical Association.

Learn more

Credentialing

A physician, midwife or dentist must have an appointment to the Fraser Health Medical Staff prior to practising in a FH hospital or residential facility.

In order to become a member of the FH Medical Staff a practitioner must formally apply to the Board of Directors and submit a prescribed list of credentials.

This application process is generally referred to as “credentialing" in that a practitioner’s credentials are submitted for review.

The Fraser Health Medical Staff are “governed” by the Medical Staff Bylaws and Rules. The Bylaws outline the application process.

Medical Staff credentialing for all FH facilities is managed by a central Credentialing Office in the Office of the Vice President Medicine.

Practitioners should contact the Credentials Office with questions about applications for appointment to the Medical Staff.

A practitioner will be provided with an application for appointment to the Medical Staff following a prescribed Search and Selection Process when a vacancy exists. This process is described in the Rules.

Vacancies are determined by a Program, Regional Department or Regional Division.

Once a practitioner is determined through the selection process to be a preferred candidate, an application form will be provided. Once completed, the application will be reviewed by the Head(s) of Department (local) and the Regional Department Head(s) before being recommended to the FH Medical Advisory Committee (HAMAC).

HAMAC recommends the appointment of the practitioner to the Board of Directors.

The relationship between the Board and the Medical Staff and each practitioner as a member of the Medical Staff is described in the Hospital Act Regulation.

As well as appointing practitioners to the Medical Staff, the Board also grants "privileges" or specific permission to engage in certain medical acts in the facilities. Privileges are defined in the Rules.

Questions regarding BC registration and licensure?

Go to the College of Physicians & Surgeons of BC - Physician's Area

Credentialing Coordinators

Name Assigned Department Phone

Cindy L. Dawson

 

 

  • Medicine
  • Critical Care
  • Cardiology
  • Geriatric Medicine
  • Mental Health & Substance Use

604-217-0953

 

 

Brenda Ogren
  • Family Practice
604-217-4385

Krista Jones

 

  • Surgery (and Dentists)
  • Anesthesia
  • Pediatrics

604-217-6959

 

Dawn Drummond

 

 

  • Infection Prevention & Control and Public Health
  • Medical Imaging
  • Lab Med & Pathology
  • Nurse Practitioners

604-418-7426

 

 

Lesley McKay
  • Emergency Medicine
  • Hospitalists
  • Obstetrics/Gynecology (and Midwives)

604-217-4652

 

For all other credentials-related requests or questions, please email credentials.office@fraserhealth.ca

 

Credentialing Terms & Definitions List

Affiliation Agreement

An agreement between the Board of Directors of FHA and the Board of Governors of a post-secondary educational institution.

Appointment

The process by which a Physician, Dentist, Midwife or Nurse Practitioner becomes a Member of the Medical Staff of the FHA. Appointment does not constitute employment.

Board

The Board of Directors of the FHA which is the governing body of the FHA.

Chief Executive Officer (CEO) / President

The person engaged by the FHA to provide leadership to the FHA. This individual is responsible for management of the Hospitals and other facilities and Programs operated by the FHA in accordance with the bylaws, rules and policies of the FHA.

Clinical Fellow

A Physician, Dentist, Midwife or Nurse Practitioner temporarily attached to facilities and Programs operated by the FHA for the purpose of postgraduate training in accordance with an Affiliation Agreement.

Clinical Trainee

A member of the Medical Staff temporarily attached to the FHA for the educational purpose of gaining additional experience or training.

Consultant

A Member of the Medical Staff who has been asked to evaluate a patient and provide recommendations for care (consultation only), write orders for care and follow up (consultation with ongoing care) or assume the entire care of the patient and become the Most Responsible Practitioner (consultation with transfer of care).

Coroner's Act

The Coroner's Act, [RSBC 1996] Ch. 72, as amended or replaced from time to time.

Credentials

Refers to the qualifications, professional education and training, clinical experience and experience in leadership, research, education, communication and teamwork that contribute to the Medical Staff member’s competence, performance and professional suitability to provide safe, high quality healthcare services.

Credentials and Privileges Committee

The advisory committee to FHA on medical, dental, midwifery and nursing matters, as described in Article 8 of the Bylaws.

Dentist

A Member of the Medical Staff who is duly licensed by the College of Dental Surgeons of British Columbia and who is entitled to practice dentistry in British Columbia.

Designate

A Member of Medical Staff who has the appropriate Credentials and Privileges afforded to them by the Bylaws or is an Intern, Resident, Clinical Fellow/Trainee under the direct supervision of the Most Responsible Practitioner.

Division

A component of a Regional Department composed of members with a clearly defined sub-specialty interest.

Division Head

A Member of Medical Staff appointed by and accountable to the Regional Department Head to be in charge of and responsible for the operation of and quality of care within a Division.

Evidence Act

The Evidence Act, [RSBC 1996] Ch. 124, as amended or replaced from time to time.

Executive Medical Director

The Physician, appointed by FHA and accountable to the VP Medicine, to provide professional leadership for co-ordination and direction of medical care within a group of Programs.

Facility

A health care facility and owned and operated by FHA.

FOIPPA

The (FOIPPA) Freedom of Information and Protection of Privacy Act, [RSBC 1996] Ch. 165, as amended or replaced from time to time.

HAMAC

The advisory committee to the Board on medical, dental, midwifery and nurse practitioner matters, as described in Article 8 of the Bylaws.

Head of Department (local)

The Member of the medical staff in each facility or community program where the Regional Department operates, appointed by the Board and responsible to the Regional Department Head. The Head of Department (local) is responsible for coordinating functions of the regional department in that facility and will be a member of the Multidisciplinary Healthcare Coordinating Committee.

Health Professions Act

The Health Professions Act, [RSBC 1996] Ch. 163, as amended or replaced from time to time.

Hospital

A health care facility subject to the Hospital Act and Regulations of British Columbia and owned and operated by FHA.

Hospital Act Regulations

The Hospital Act, [RSBC 1996] Ch. 200 and associated Regulations, as amended or replaced from time to time.

House Staff

Members of the Medical Staff temporarily engaged by or attached to the FHA for the purpose of post graduate training in accordance with an Affiliation Agreement.

Human Tissue Gift Act

The Human Tissue Gift Act, [RSBC 1996] Ch. 211, as amended and replaced from time to time.

Locum Tenens

A practitioner appointed to the Medical Staff for the purposes of replacing an existing Medical Staff member or a vacancy for a limited time.

Medical Care

For the purposes of this document, Medical Care includes the clinical services provided by Physicians, Dentists, Midwives and, Nurse Practitioners.

Medical Staff

The physicians, dentists, midwives and nurse practitioners who have been granted privileges by the Board to practise in the facilities and Programs owned or operated by the FHA.

Medical Staff Association

The organization established pursuant to Article 7 of the Bylaws.

Medical Staff Bylaws (Bylaws)

The Bylaws promulgated by the Board pursuant to the Authority of the Hospital Act governing the relationship and responsibilities between the Board and Medical Staff, and the organization and conditions of practice of the Medical Staff in the facilities and Programs owned or operated by FHA.

Medical Staff Rules (Rules)

The Rules approved by the Board governing the day-to-day obligations of the Medical Staff in the facilities and Programs owned or operated by FHA.

Medical Students

Undergraduate medical students attached to the FHA for the educational purpose of gaining practical clinical experience during a specified rotation administered by the University in which they are registered.

Member

A Physician, Dentist, Midwife, or Nurse Practitioner appointed to the Medical Staff of FHA.

Midwife

A Member who is duly licensed by the College of Midwives of British Columbia and who is entitled to practice midwifery in British Columbia.

Most Responsible Practitioner (MRP)

The Physician, Midwife, Nurse Practitioner or Oral/Maxillofacial Dental Surgeon who is a Member of Medical Staff and has the overall responsibility for the management and co-ordination of care of the patient at any given time.

Multidisciplinary Healthcare Coordinating Committee

A committee with representation from medical, nursing and allied health professional staff at a facility or Community Program which functions to co-ordinate the delivery of health care in that facility or community program.

Nurse Practitioner

A member of the medical staff or a person given permission to practice as a non-employed allied health professional who is duly registered as a Nurse Practitioner with the College of Registered Nurses of British Columbia.

On Call

Medical Staff Member A Member designated to be available to provide after hours service.

Oral and Maxillofacial Surgeon

A dentist who holds a specialty certificate from the College of Dental Surgeons of British Columbia authorizing practice in oral and maxillofacial surgery.

Physician

A Member who is duly licensed by the College of Physicians and Surgeons of British Columbia and who is entitled to practice medicine in British Columbia.

Policies

The term policy refers to all corporate and clinical policies in force at the Ministry of Health or at Fraser Health Authority.

Practitioner

A duly qualified licensee in good standing of the College of Physicians and Surgeons of BC, the College of Dental Surgeons of BC, the College of Midwives, or College of Registered Nurses of British Columbia of BC who is not a Member.

President of Medical Staff

The representative of the Medical Staff elected to that office to advocate for individual or group Medical Staff interests.

Primary Regional Department

The Regional Department to which a Member is assigned according to his/her training, and within which the Member delivers the majority of care to patients.

Privileges

The right granted by the Board to Members to provide specific types of medical care within the facilities and programs of the Health Authority. Privileges are differentiated into:

  • Core Privileges: Those activities or procedures which are permitted by virtue of possessing a defined set of credentials usually obtained as part of a standard training program.
  • Non-Core Privileges: Those activities and procedures which are outside of the core privileges, that require specific training or certification or reflect advances in medical practice not currently reflected in core privileges

Procedural Privileges

A permit granted by the Board to a Member authorizing the Member to perform specific procedures within the scope and limits of each Practitioner's permit to practice in a Facility.

Program

An ongoing care delivery system under the jurisdiction of FHA for coordinating a specified type of patient care.

Program Medical Director

The Member appointed by FHA and accountable to the VP Clinical Operations, with professional accountability to the VP Medicine, to be in charge of and responsible for the operation of and quality of care within a Program. For the purpose of these Rules a Program Medical Director may be the Regional Department Head for a Program consisting of a single Regional Department.

Regional Department

A major subunit of the Medical Staff composed of members with common clinical or specialty interest. Regional Department Head The Member accountable to the Program Medical Director and responsible for the operation of and quality of care within a Regional Department. For the purpose of these Rules a Program Medical Director may be the Regional Department Head for a Program consisting of a single Regional Department.

Regional Division

A component of a Regional Department composed of members with a clearly defined sub-specialty interest.

Regional Division Head

The Member appointed by the Board and responsible to the Regional Department Head. The Regional Division head is responsible for co-ordinating the operation of and quality of care within a Regional Division.

Regulations

The Regulations made under the authority of the Hospital Act.

Resident

A medical learner in a postgraduate training program.

Signature

An authentic signature and/or electronic sign off.

Specialist

A physician with "Fellowship" or "Certificate" status with the Royal College of Physicians and Surgeons of Canada or equivalent, or relevant clinical experience and licensed to practice as a Specialist by the College of Physicians and Surgeons of British Columbia.

Temporary Privileges

A permit to practice in the Facilities and Programs that is granted to a Member for a specified period of time in order that he/she may provide a specific service.

Vice President Medicine

The Physician, appointed by the CEO, responsible for the coordination and direction of the activities of the Medical Staff.

Vital Statistics Act

The Vital Statistics Act, [RSBC 1996] Ch. 479, as amended or replaced from time to time.

Year

The fiscal year adopted by the FHA, defined currently as April 1 of a given year to March 31 of the following year.

Credentialing FAQ's

Questions at a glance:

Answer

Yes, a physician, midwife or dentist may work in more than one facility in the FH. A practitioner is appointed to the Medical Staff of the Fraser Health Authority, not to the Medical Staff of individual hospitals. A member of the FH Medical Staff is then granted privileges to practice in specified facilities and/or programs. Each Regional Department/Division makes recommendations on granting privileges to members.

Answer

Sometimes it is necessary for a practitioner to practice in an FH facility for a specific purpose or limited period of time (i.e. organ removal team, super-specialist consult, etc). A Temporary Appointment with Temporary Privileges is often used in FH to permit a practitioner to begin practice in a FH facility before his/her Application for Appointment has been reviewed and approved by the Board. Under these circumstances, and upon receipt of a completed Application for Appointment form, the relevant Regional Department Head may, by issuing a letter to the applicant, grant a Temporary Appointment with Temporary Privileges to the practitioner which will remain in effect only for the purpose or period specified, or pending the Board’s review of the practitioner’s Application for Appointment.

Answer

Yes, physicians, midwives and dentists may direct inquiries about opportunities to apply for vacancies to Program Medical Directors, Regional Department Heads, Heads of Department (local) or the FHA Credentials Office (Credentials.Office@fraserhealth.ca)

Answer

In order for a member of the Medical Staff to be granted continued membership upon review by the Board, the member must have demonstrated that any required continuing professional development activity has been completed in the previous appointment year.

Answer

Appointments to the Medical Staff are for a 2 year period. Reappointment, or continued membership on the Medical Staff requires a member to complete a Renewal of Membership Application form. This form is provided by the FH Credentials Office in advance of the conclusion of the member’s current appointment term. The completed form is reviewed by Head(s) of Department (local), Regional Department Heads, and HAMAC before being presented to the Board.

Answer

Only physicians, midwives and dentists who work in FH hospitals (including extended care hospitals) are required to have appointments to the Medical Staff. Once a practitioner becomes a member of the Medical Staff, s/he will undergo a prescribed orientation program. See Medical Staff Rules Appendix 3.

Answer

The timing for processing appointment applications is specified in the Medical Staff Bylaws (sec 4.3). An application must be reviewed by the Board within 120 days of receipt of a completed application by the FH Credentials Office. See Medical Staff Rules Appendix 2.

Answer

Yes, the Health Authority) Medical Advisory Committee (HAMAC) is responsible to review applications for appointment and renewal of membership and to make recommendations regarding each applicant to the Board.

See Bylaws Article 8

See Medical Staff Rules sec 2.3 and sec. 3.6.

Answer

It is recommended that a member first discuss changes to Medical Staff Category or privileges with her/his Head of Department (local). If the relevant medical leaders are supportive of the change, a form requesting the change may be obtained from the FH Credentials Office.

Answer

No. The process of applying for an appointment to the Medical Staff is the same regardless of the Category or privileges desired by the applicant. This is also true of the application for continued membership (bi-annual review).

Answer

The Application for Appointment form contains the list of information and documents that an applicant must produce. Key elements of the required information are: professional training, proof of license and liability insurance coverage, work history, names of 3 references, a declaration and consent to allow FH access to information, etc.

See Bylaws Article 4.

Answer

Yes. An appointment to the Medical Staff granted by the Board specifies the Category (i.e. Provisional, Consulting, etc.), the Department (which usually indicates specialty), Site(s) Specialty, and the Privileges at each Site. An applicant is normally appointed to a “primary Department” but may also be appointed to another Department where advantageous to the FH and the member.

Answer

“Eligibility” refers to whether an applicant meets all the criteria outlined in the Bylaws to become a member of the Medical Staff.

Answer

The credentialing process is outlined clearly in the Bylaws. Sec. 4.3 addresses “Process for Application” (implying “appointment”) and sec. 4.4 addresses procedure for Review (implying “continued membership”). The credentialing process ensures due process and fair administrative procedure and is compliant with the requirements in the Hospital Act Regulation. Fraser Health is required to comply with the process and procedures as outlined in the Bylaws.

MEDICAL STAFF QUALITY IMPROVEMENT

A PARTNERSHIP BETWEEN FRASER HEALTH AUTHORITY (FHA), SPECIALIST SERVICES COMMITTEE (SSC), AND DOCTORS OF BC (DoBC)

DoBC, SSC, and various BC health authorities have partnered together with a goal to increase physician and medical staff engagement across the province.

Programs supported by MSQI  include:

• Physician Quality Regional Safety Team (PQRST)
• System Redesign
• Sauder
• MSA for QI
• Physician Leadership and QI Training 
• Advisory Board Talent Development Program

Contact Angela.Tecson@fraserhealth.ca for more information.

Are you passionate about Quality Improvement? Have you identified an area in your Fraser Health workplace that could use QI?

Here’s how PQRST can help:

• Provide you up to 5 hours per week of sessional support (Doctors of BC sessional rate).
• Teach you the key principles and techniques about QI, Leadership and Change Management.
• Support your QI activities with dedicated technical staff (QI Consultant, Data Analyst, etc)
• Provide coaching and mentoring support by expert physician QI Advisor.
• Ensure your project receives strong support and oversight from the Joint Steering Commiteee which includes representation from senior leaders from: FHA, HAMAC, SSC.

 

PQRST GOALS

The PQRST will create the capacity and culture within the FH Physician Community to enable widespread engagement and cooperation with FH to improve the quality of care for our patients.

 

PQRST MISSION

• Promote a culture of Quality and Safety
• Promote the IHI Triple aim:
     o Improve the patient experience of care (including quality and satisfaction)
     o Improve the health of populations
     o Reduce the per capita cost of health care
• Align with Provincial and FH Quality Initiatives
• Provide learning opportunities for the Physicians of FH to increase their capability for QI
• Provide learning opportunities for the PQRST members to enable them to better carry out their duties in leadership and Change Management
• Facilitate Physicians and Teams in Quality Improvement
• Provide infrastructure, where possible, to assist with Physicians QI projects

 

PQRST TACTICS

• Clear Expectations and Procedures - Medical and Administrative Sponsor
• Clear, Frequent formal communications - Formal Monthly Reporting
• Follow established QI guidelines
• Early Intervention
• Executive Buy In, Access and Intervention

 

PQRST TRAINING

• 13 full-day, paid, training sessions
• Real Projects
     o Project influences which tools and methods are emphasized to you
     o Theory Based Approach; outcomes and solutions are unknown
• Active Learning
• Reference Materials
• Adult Learning Focus
• Learning to consult

 

If you are interested in learning more about PQRST, please contact Angela Tescon at Angela.Tecson@fraserhealth.ca

To find out about ongoing PQRST projects, please visit our SharePoint site here. (SharePoint sites must be viewed via the FH intranet.)

In order to enable physicians to make an improvement in their workplace, FH/SSC RQI will assist physicians in accessing up to $40,000 a year for Quality Improvement projects that align with MoH, DoBC and FHA strategic priorities. Funding opportunities are offered as sessional payments for various team members. Facilitation and data support is also available from the FH/SSC RQI team.

If you have a project idea that may be a strong candidate for this funding program, please contact HealthSystemRedesign@fraserhealth.ca or Angela.Tecson@fraserhealth.ca for more information.

The application form is also available on SharePoint here. (SharePoint must be viewed via the FH intranet.)

The Physician Leadership Program through the Sauder School of Business Executive Education has been developed in partnership with BC Health Authorities, BC Patient Safety Quality Council and UBC Faculty of Medicine. This program is available to all medical staff of Fraser Health (physicians, nurse practitioners, midwives and dentists). Funding for this program is provided by SSC and participation is endorsed by FHA.

Cohort 8 Dates and Location

UBC Robson Square, 800 Robson Street, C180
     • Module 1 – February 23-25, 2017
     • Module 2 – March 30, 31, April 1, 2017
     • Module 3 – April 27, 28, 29, 2017
     • Module 4 – Presentations and Graduation – June 23, 2017

Applicants must be able to commit to all of the dates mentioned above, and those interested must begin the registration process by January 20, 2017. All registrations must be completed by February 1, 2017.

If you are interested in developing your leadership skills, please contact Tracey Giles (Tracey.Giles@fraserhealth.ca) as soon as possible in order to secure your seat for Cohort 8.

View Informational brochure here.

More information to follow.

Provided by the SSC and endorsed by FHA, physicians within the health authority can access up to $10,000 annually for tuition and travel costs in order to develop leadership and QI skills. Potential training programs include, but are not limited to, Six Sigma, Quality Academy, and Physician Leadership Institute (formerly PMI).

Please contact JCCTraining@doctorsofbc.ca or view the Leadership Training Scholarship website here for more information.

Fraser Health offers full funding for physicians to attend three half-day entry-level sessions to develop leadership skills. Attendance at all workshops is not required.

Cohort 4 Dates and Location

Sheraton Guildford Hotel, Surrey
Time: 8am-2pm (lunch provided)

Leading Change
February 9, 2017

Facilitating Effective Teamwork
May 2, 2017

Hardwiring for Service Excellence
September 12, 2017

Please contact Jag Sandhu (Jag.Sandhu@fraserhealth.ca) by January 27, 2017 to register for Cohort 4.

View Informational brochure here