Ensuring patients get appropriate care

For so many years the patient voice has been missing in health care, contributing to varying outcomes for patients. By incorporating the voice of the patient throughout many areas of this work, Appropriateness of Care will ensure the goals of the initiative will be met. The Appropriateness of Care vision, ‘Right care provided by the right provider, to the right patient, in the right place, at the right time, resulting in optimal quality care,’ is so promising for our patients and families, but also will make sure our patients will be getting the safest quality of care.

Heather Thiessen, patient and family advisor

Several factors contribute to inappropriate care, including availability of services, access to care, variation in physician practices, and lack of definitive evidence upon which physicians can base decisions about testing and treatment. This can lead to uncertainty and variation in how physicians make decisions.

Saskatchewan’s health system is addressing these factors through the provincial Appropriateness of Care Program.  The program is led by two physicians and an administrative co-lead, with support from the Ministry of Health and the Health Quality Council (HQC).

The work of the provincial program is based on the framework pictured below. This framework is designed to support physicians, health care providers, patients, and families in improving appropriateness of care throughout the health system.

Appropriateness of Care Framework

Choosing Wisely Saskatchewan

Choosing Wisely Saskatchewan is part of a larger national campaign, Choosing Wisely Canada , which is aimed at helping clinicians and patients engage in conversations about unnecessary tests and treatments, and make smart and effective choices to ensure high-quality care. 

HQC is coordinating Choosing Wisely Saskatchewan efforts in collaboration with provincial organizations including the Saskatchewan Medical Association, the University of Saskatchewan’s College of Medicine, and the provincial Appropriateness of Care Program. Together we are implementing the following strategy, through the engagement of clinicians, patients, and medical students:

Clinicians

  • Present on CWC at meetings and in the community

  • Identify, engage, and grow local clinical leaders and champions

Patients

  • Leverage national patient materials, tailor to local audience, then disseminate broadly

  • Engage patients in regional activities

Medical Education

  • Engage and align activities with local medical school by connecting into national STARS program

  • Integrate resource stewardship as a core competency

Implementation

  • Work with local stakeholders to establish and execute shared improvement priorities

  • Support grassroots/frontline CW initiatives

Measurement

  • Work with regional data to measure baseline and change

  • Build research capability

Partners

  • Health Quality Council
  • Saskatchewan Medical Association
  • Regional Health Authorities
  • Ministry of Health (Provincial Appropriateness of Care Program)
  • College of Medicine, University of Saskatchewan
  • eHealth Saskatchewan
  • Saskatchewan Cancer Agency
  • Provincial Patient and Family Advisors

Want to stay connected about Choosing Wisely Saskatchewan?

Join us on Twitter:  @ChooseWiselySK

For more information about Choosing Wisely Saskatchewan, please contact

Choosing Wisely Saskatchewan Coordinator

306-668-8810

ChoosingWiselySK@hqc.sk.ca

Provincial Appropriateness Projects

The Appropriateness of Care Program coordinates a number of provincial projects aimed at improving care where evidence suggests there may be inappropriate care or unjustified variation (which can be a sign of overuse, underuse, or misuse) in care delivery. For each project, a group of clinicians with special expertise in the topic area, called a clinical development team, identifies reasons for variation or inappropriate care, and develops strategies for improvement. As part of this work, teams engage with patients to incorporate their input and perspectives.

Imaging of Low Back: MRI and CT Imaging of Lumbar Spine

What's the opportunity?

Recent evidence suggests that diagnostic imaging of the lower spine, particularly for patients with acute low back pain, may have minimal impact on patient treatment options or outcomes. Data from Saskatchewan suggests that some patients with low back pain may be receiving both a lumbar spine CT and a lumbar spine MRI for various reasons. After reviewing the medical literature and guidelines, a team of clinicians has concluded that, where imaging is warranted, an MRI is the most appropriate test for the majority of lower back pain conditions, except for a few conditions where a lumbar spine CT should be used for diagnosis and treatment. Inappropriate use of MRI and CT testing may contribute to increased wait times for those patients who truly require this testing, may put patients at risk for radiation exposure (for those who receive a CT scan) as well as further unnecessary testing and invasive procedures.

Choosing Wisely Canada

Provincial Appropriateness of Care Initiative
"Better Care, Made Easier"

What action is being taken?

The clinical development team has developed a combined lumbar spine MRI/CT checklist based on best practice guidelines, including the Choosing Wisely Canada recommendations. The checklist provides a list of different clinical indications for ordering lumbar spine CT/MRI for patients with low back pain and is designed to be a decision support tool for physicians.

The 2018-02-08_L-Spine_Imaging_Checklist_New_Design_Draft builds on earlier work done as part of two separate MRI and CT Lumbar Spine Projects.   The MRI lumbar spine checklist was rolled out provincially in May 2016, to all sites with MRI services, and the CT lumbar spine checklist was piloted in five locations in Saskatchewan from April to November 2017.  The combined lumbar spine imaging checklist will be piloted in Moose Jaw from May to July 2018.  After the pilot, the Provincial Appropriateness of Care team will work with the Saskatchewan Health Authority to develop a provincial implementation plan for Fall 2018. Who is Involved?

The clinical development team comprises orthopedic surgeons, a neurosurgeon, radiologists, family physicians, a chiropractor, and patients from the Saskatchewan Health Authority along with staff from the Ministry of Health and the Health Quality Council.

Who is Involved?

The clinical development team comprises orthopedic surgeons, a neurosurgeon, radiologists, family physicians, a chiropractor, and patients from Regina Qu’Appelle, Saskatoon, Five Hills, and Kelsey Trail, along with staff from the Ministry of Health and the Health Quality Council.

For more information, please contact:

Deb Gudmundson Deb Gudmundson, Consultant, Ministry of Health
debra.gudmundson@health.gov.sk.ca | 306-222-2371

Pre-operative Testing and Evaluation for Elective Surgery

What’s the Opportunity?

Pre-operative tests for low-risk surgical procedures are performed frequently in Saskatchewan. Recent Canadian Institute for Health Information (CIHI) data (2013) found that 10,000 pre-operative tests were conducted for every 35,000 low-risk procedures. Evidence shows that routine testing in patients undergoing low-risk procedures does not improve outcomes or change clinical management. However, it may lead to further unnecessary testing and the cancellation of surgery, as well as increases in patient anxiety and cost.

Choosing Wisely Canada

Provincial Appropriateness of Care Initiative
"Better Care, Made Easier"

What action is being taken?

The goal of this project is to standardize and reduce inappropriate pre-operative testing and evaluation of patients scheduled for elective surgery, through the development and implementation of standardized provincial pre-operative testing, consultation and medical history and physical examination guidelines.

Choosing Wisely Canada has produced evidence-based recommendations regarding pre-operative tests for low-risk surgical procedures. For example, the Canadian Anesthesiologists’ Society recommends that physicians do not order baseline laboratory studies (complete blood count, coagulation testing, or serum biochemistry) for asymptomatic patients undergoing low-risk non-cardiac surgery.

Draft provincial standard guidelines for pre-operative testing required for patients undergoing elective surgeries have been developed, based on the Choosing Wisely Canada recommendations. The guidelines will be tested in North Battleford and Lloydminster in Spring/Summer 2018. The Provincial Appropriateness of Care Program team will work with the Saskatchewan Health Authority to develop a subsequent implementation plan for replicating it in other locations.

Who is involved?

The clinical development team of clinical experts in anesthesia, surgery, and internal medicine, family medicine, pre-operative nurses from North Battleford, Prince Albert, Regina, Saskatoon as well as patient advisors leads this work, with support from the provincial Appropriateness of Care Program team including two physician leads, an administrative lead and staff from the Ministry of Health and the Health Quality Council.

Local pre-assessment clinics, anesthesiologists and internists will be involved in testing and replicating the provincial pre-operative testing guidelines, with support from quality improvement consultants and data analysts from the Saskatchewan Health Authority.

For more information, please contact:

Deb Gudmundson Deb Gudmundson, Consultant, Ministry of Health
debra.gudmundson@health.gov.sk.ca | 306-222-2371

Roy Romanow Provincial Laboratory Testing: Vitamin D

What's the opportunity?

To determine whether Vitamin D testing in this province is consistent with Choosing Wisely Canada recommendations, the Roy Romanow Provincial Laboratory (RRPL) examined ordering practices of Saskatchewan physicians. They found that, while the vast majority of doctors are using Vitamin D testing appropriately, a handful order a disproportionally large volume of tests relative to their peers.

Choosing Wisely Canada

What action is being taken?

In partnership with medical health officers and other clinical specialists, the RRPL developed and distributed to physicians across the province a clinical guideline for ordering vitamin D testing, along with information for patients about testing and dietary and other sources of the vitamin. Click here for the clinical guideline and here for patient information.

For more information, please contact:

Patrick O’Byrne, Consultant, Ministry of Health
patrick.obyrne@health.gov.sk.ca | 306-787-3129

Antimicrobial Stewardship Programs

What's the opportunity?

In 2013, Accreditation Canada made antimicrobial stewardship programs a required organizational practice, to ensure patients are receiving the right drug, dose, duration, and route when treating antimicrobial-related illnesses in acute care facilities.

Choosing Wisely Canada

What action is being taken?

The provincial Ministry of Health is supporting implementation of this program across Saskatchewan’s health system. The Roy Romanow Provincial Laboratory has developed an antibiotic susceptibility guideline to help clinicians selecting the best antibiotic for each patient’s care.

Contact:

Contact the Saskatchewan Health Authority to learn more about local antimicrobial stewardship programs. 

Examples:

Acute Stroke Pathway

HQC is contributing to the work of the Saskatchewan Acute Stroke Pathway. HQC researchers provide measurement support to the pathway development team and to health regions that are testing and implementing the pathway. This work is led by the Ministry of Health. Click here for more information.

Education and training

Education and training in clinical quality improvement is a key foundational piece to support appropriateness work. Increasing the quality improvement capacity and capability in the Saskatchewan health care system is an important component for driving and sustaining these improvement efforts.

HQC offers a 10-month Clinical Quality Improvement Program (CQIP) in partnership with the Saskatchewan Medical Association and the Ministry of Health. To learn more about this program, please see Clinical Quality Improvement Program under HQC’s Education and Learning webpage.

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For more information about Ensuring Patients Get Appropriate Care, please contact:

Patrick Falastein

306-668-8810 (ext 116)

pfalastein@hqc.sk.ca

External Partners

Dr. Gary Groot

Clinical Co-Lead , Provincial Appropriateness of Care Program

Saskatoon

Deb Gudmundson

Administrative Co-Lead , Provincial Appropriateness of Care Program

Regina

Dr. David Kopriva

Clinical Co-Lead , Provincial Appropriateness of Care Program

Regina