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Photo of Tanya Swanson and Ana De AlaResearch & Innovation
Working together
A new initiative at Concordia Hospital is
improving patient care and reducing
length of stays
Occupational therapists Tanya Swanson and Ana De Ala review a patient's chart following a Daily Action Round.
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By Joel Schlesinger
Summer 2018

Patient One came to hospital with a high fever from a urinary tract infection.

But, as it turned out, the elderly woman also suffered from dangerously high blood pressure and blood glucose that had to be controlled before she could go home.

Patient Two suffered a minor fracture after falling at his personal care home.

He was now medically stable, and ready to begin transitional planning with support from a physiotherapist prior to returning to his long-term care home.

Patient Three suffered a minor stroke a few days earlier.

He had already seen a neurologist, and an occupational therapist and home-care co-ordinator were hammering out the final details of his care plan to ensure he could manage at home with his caregiver.

"He's medically stable, and ready to go home hopefully today . . . if everything goes right," says the nurse in charge of his care.

One by one, the files of more than 30 patients are reviewed by a team of health-care providers gathered in the family medicine unit at Concordia Hospital. In each case, the team - which includes nurses, a physiotherapist, an occupational therapist, a social worker, a home care co-ordinator, a pharmacist and other staff - discusses the patient's medical status, action items for the day and transitional plan.

Once the review is complete, a unit clerk updates the patient's status on Oculys, a computer program that keeps tabs on the flow of patients within the hospital and displays the information in real time on a flat-screen monitor above the central nursing desk.

These brief morning meetings - they usually last about 20 minutes - are known as Daily Action Rounds (DARs). Launched late last summer, they are a key element of a "collaborative care" initiative at Concordia that is designed to encourage health-care providers from different disciplines to work together to ensure patients receive the very best care possible.

As an idea, collaborative care may not sound all that innovative. After all, don't health-care providers collaborate by definition? The answer to that question is yes, but they don't always do so as well as they might.

The fact is that in the day-to-day routine of providing care to patients in hospitals, clinics, personal care homes and other facilities, breakdowns in communication are more common than many health-care providers would like to admit, says Katherine Graham, Director of Access and Transition at Concordia Hospital. And these breakdowns can lead to delays in how quickly patients are assessed, treated and even discharged from hospital, she says.

That was indeed the case at Concordia roughly two years ago when it was ranked among the worst hospitals in Canada in terms of patients staying longer than necessary before being discharged, a measure more commonly known as "length of stay."

"We were spending a ton of money, but our outcomes weren't great," says Graham, a registered nurse and specialist in collaborative care and patient flow. "So, it wasn't about spending more money, but rather looking at 'how' we were working."

As a result, Concordia took action. It analyzed internal processes and created a team of collaborative professionals focused on the goal of achieving better length of stay targets. A new culture was established, one that emphasized efficient patient flow as everyone's responsibility.

"Health care is too complex to think that one profession has all the answers, so we need to work together."

It wasn't easy, says Graham.

"The hardest piece for a team is to be okay with the idea that we need to change," she says.

But the effort paid off. Today, Concordia is considered one of Canada's most improved hospitals and has reduced its length of stay in some units by 50 per cent.

Graham is quick to point out that the improvement does not mean staff were previously doing a bad job. Rather, it means they weren't communicating with each other about a patient's care as well as they could have been because no framework existed to promote increased collaboration.

That's where DARs come into play - they provide a framework to encourage collaborative care.

"Communicating is one thing, but understanding what everyone brings to the table is quite another," Graham says. "If you know the role of others really well, and respect and appreciate them, the work is so much easier and to the patient's benefit."

Kim Goodbrandson, Clinical Manager for Family Medicine at Concordia, says one of the main challenges in providing care in the unit was making sure team members see a patient when they are supposed to.

"A patient could be medically stable, but could also be waiting to be seen by the occupational therapist or home care," she says. "And the delay might have been caused simply because these allied care professionals had not been notified the patient was ready to return home."

This kind of communication breakdown could keep a patient in a bed longer than necessary, she says.

Clichés aside, caring for a patient is truly a team effort. "And when we collaborate together, we get the work done very efficiently," Goodbrandson says.

Photo of Will Husarewycz and Tabitha Bear
Physiotherapist Will Husarewycz and Tabitha Bear, Interim Manager of Rehabilitation Services, discuss a patient's treatment plan during a Daily Action Round.

Of course, collaborative care is not an entirely new concept within the Region, but it is becoming increasingly important as a means for improving care.

"It's been going on for 20 to 30 years," says Carol Schaap, the Region's Primary Care Initiatives Leader for Family Medicine/Primary Care.

Promoted across Canada by the Canadian Interprofessional Health Collaborative (CIHC), interprofessional collaborative health care has been taught in education programs in just about every health profession for more than a decade.

Early initiatives in the Region included a program in hospitals in which student nurses, physiotherapists and occupational therapists were placed in clusters to work with each other closely for their practicums. Since about 2012, the Region also has been slowly but surely moving toward entrenching this model at hospitals and care centres throughout the city.

"Before, we tended to work all too often in silos," Schaap says. "Physicians knew what physicians did, and social workers knew what social workers did, and we didn't really know a lot about each other."

This led to less-than-ideal care for patients - particularly aging patients with multiple chronic conditions requiring more than one professional's medical expertise.

"I am pretty proud of what we've done and how we've done it."

"This [the need to care for older patients with complex issues] is a huge, worldwide phenomenon," she says, adding it's not just a challenge particular to Canada's health-care system. "Health care is too complex to think that one profession has all the answers, so we need to work together."

And the stakes are too high not to embrace greater collaboration. Lives are literally at risk.

"When we look at critical incidents - when things go wrong - a huge amount of the time it's because we had poor communication or handoffs," she adds. "It's because we haven't worked together well as a team."

Schaap notes the collaborative care approach aims to break down the hierarchy of the traditional model, which typically does not foster open dialogue and partnership. Rather than physicians at the top, followed by nurses, physiotherapists, and other health professionals, the collaborative care model flattens that top-down structure. That way, health-care aides, security and other staff are empowered to speak out when they see something wrong or requiring the attention of others.

"In an [emergency department], for example, do the security people feel part of that team - with an equal voice - so when they see someone there for a long time, they can bring that concern up with a physician or a nurse?" she asks.

With the old hierarchical model, that may not have necessarily been the case.

"With a collaborative care model, health-care aides, the physician, really, all the staff, and the patient and family are on equal footing, and that helps ensure that all of us as health-care providers are listening and hearing what everyone has to say."

In implementing the new model, the Region has adopted a framework from CIHC involving six pillars of collaborative care:

  • Person-centred care (the patient comes first)
  • Role clarification of health-care providers
  • Interprofessional communication
  • Interprofessional conflict resolution
  • Team functioning
  • Collaborative leadership.
Members of a collaborative care team at Concordia Hospital gather for a Daily Action Round
Members of a collaborative care team at Concordia Hospital gather for a Daily Action Round.

Becoming competent in these areas is more important than ever, as the system is increasingly asked to do more with finite resources, says Susan Bowman, Rehabilitation Services Manager at Deer Lodge Centre - the third largest health facility in Manitoba.

"My job covers occupational therapy, physiotherapy, recreational therapy, the day hospital - including the motor-neuron disease clinic - and the Movement Disorder Clinic."

It's a lot of responsibility for one individual, but by no means is Bowman alone in that respect.

"The whole Region is going through clinical redesign, so it's absolutely essential to have a system that makes sure we take full advantage of everybody's skill set and scopes of practice, so we can provide excellence in care," she says.

"It's paying off, and now we're one of the most improved hospitals across Canada."

The overhaul, guided by recommendations in a 2016 provincial report, aims to consolidate services across Manitoba to increase efficiency and promote better use of resources in the face of a growing and aging population.

Changes included the transfer of some of the long-term care beds at Deer Lodge to Riverview Health Centre, while rehabilitation beds were moved from Riverview to Deer Lodge. At Concordia, the emergency department is scheduled to be converted to a Walk-In Connected Care community clinic.

"So as these programs are moved, it's critical for us to work collaboratively as a team because we all might be working in a different unit with different professionals than what we're used to," Bowman says. "And we need to trust, communicate, and rely on each other to provide the care patients need."

Of course, systematic change takes time, says Schaap, who leads "Collaborate," an annual workshop for health-care teams in the Region.

"We can only take about 60 people a year," she says. And participants' vocations and goals can vary greatly. For example, "There might be a care team at a hospital working with seniors trying to reduce cases of malnutrition, or another seeking to integrate Indigenous spiritual care practices - like smudging - into a hospital setting."

Progress on incorporating a collaborative approach to a flow culture is made by involving all programs and levels of an organization, says Graham. This culture change is needed and inevitable in order to provide safe patient care.

The DARs are a tangible sign of this shift in mindset and practice. They are also part of a larger effort to address an endemic problem that has proven difficult to solve in the past.

"The Region identified we had a lot of people in hospital longer than necessary simply because they were waiting for home-care services," she says.

That tied up beds for patients waiting in emergency departments and in hallways. To address the problem, Concordia set a goal to get patients back home or to an alternate community option as soon as medically stable.

Besides the DARs, another key piece of the collaborative care initiative at Concordia is technology, including the use of Oculys. The program's primary role is to provide real time data on patients to help teams follow and evaluate work flow practices that impact metrics like inpatient length of stay and emergency department wait times, says Graham.

"Oculys can trigger teams to watch for flow challenges like high emergency department volumes and admissions, which means that we need to create space or open beds to support patient flow," she says. "It can also indicate a site's ability to meet demand for emergency care by identifying which patients are ready to be discharged."

The unit teams also rely on an electronic care planning program called MedWorxx, which puts patient data at the fingertips of all team members. This software plays an important role in the DARs, with each team member having a print-out copy for each of the patients on the floor for discussion.

"The main goal is to improve our quality of care, and I really believe that's what we're doing here."

"MedWorxx provides a point-in-time snapshot," says Goodbrandson, adding that it lists why the patient is in hospital, the latest team actions, daily care goals, and the ultimate transition plan.

MedWorxx isn't comprehensive, she adds. "If you want a deep dive, you go through the chart where you can dig up all the information you need."

But it does provide the most up-to-date and relevant care information, and it is updated by all staff who work with patients. It also enables the team to identify any outstanding issues that may be a barrier to patient discharge.

While this entails more work, it's worth the effort, says Osman Gas, a nurse who works in the unit.

"It is extra work for sure - timewise - but from the other side, it improves quality of care."

Gas says updating MedWorxx for his patients allows staff on next shift to quickly get up to speed. By the same token, Gas also benefits when he returns to work from time off.

The software has also become an important tool for the team's allied partners - home-care co-ordinators, social workers, physiotherapists, and occupational therapists.

Photo of Kim Goodbrandson
Kim Goodbrandson, Family Medicine Clinical Manager, is a member of the collaborative care team.

For example, MedWorxx has helped cut the workload for occupational therapist Anna De Ala.

"The bulk of my work is to see patients and assess how they manage self-care with toileting, washing and dressing themselves, and determining if there are any home-care needs," she says.

"Before, I'd have to come really early and skim through all the charts, and that took a lot of my time to figure out who the priorities are for the day."

Now with MedWorxx, Oculys and DARs, she can quickly prioritize who needs to be seen first.

"I can pretty much tell who it is I need to see today based on who is medically stable and will soon be discharged," she says.

That's important, Graham says.

"One of the biggest things about DARs is that they are quick and concise, and focus the team on those who are medically ready for transitional planning back into the community. It is meant to drive action and remove flow barriers."

Although Concordia's collaborative care model is driven by the philosophy of "home is best," it's not about rushing them out the door. The collaborative care initiatives at Concordia - and other hospitals and health-care sites - are about giving patients the best care possible while ensuring they are not staying longer than necessary.

"We're not trying to take the patient and family out of the story," Graham says.

Rather, collaborative care seeks to engage them more effectively, establishing a clear course of care, including how long an individual will stay in hospital.

"The model is actually a way to engage patients - that we're going to address what brought them to hospital; that it will take us this long to do it; and it's best to get them back home as soon as we can."

It's also important to recognize that health care can and should be driven by data and targets. That will ultimately make the system a win-win for both the consumer and the health-care organization.

"When we're able to care and move people in an effective way, we help other hospitals that don't have capacity for patients admitted to their emergency departments."

So far so good, Graham adds.

"I am pretty proud of what we've done and how we've done it," she says in reference to reducing the average length of stay for patients and consistently meeting the demand for beds from newly admitted patients. "It's paying off, and now we're one of the most improved hospitals across Canada," says Graham.

Reducing length of stay is all fine and good, Gas adds. But even more gratifying is providing better care.

"The main goal is to improve our quality of care, and I really believe that's what we're doing here."

Joel Schlesinger is a Winnipeg writer.