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A patient comes into the emergency department with a diabetes-related infection that will lead to an amputation unless properly cared for. The patient does not have a place to live and therefore has nowhere to store medication or consistent access to healthy food. Despite wanting to do more, healthcare workers discharge the patient back to the street, knowing they’ll return within the next three months and require a below-the-knee amputation.

This, says Snehal Patel, is an example of how the existing healthcare system doesn’t always allow providers to make the best decisions for patients’ health.

“Our hospital system is really a disease-care system, not a healthcare system,” Patel, an EQUIP grad and physician, said. “It’s focused on this idea of treatment of acute disease when someone is ill but misses the opportunity to leverage the power of the hospital to improve not just individual and family health but community and population health.”

Patel’s ideal solution? Buy the patient an apartment – it will ultimately cost the health system a lot less than paying the thousands of dollars for their surgery and repeat visits to the emergency department.

But hospitals are not in the business of buying apartments. However, they can implement the next best thing: connect patients with community resources that can put them on the right track to addressing their unmet healthcare-related social needs (HRSNs) like housing and food insecurity, domestic violence and unemployment.

That was the idea behind an initiative by Patel and his team at Dell Medical School at the University of Texas at Austin. In fall 2019, Patel helped implement a QI program to ask patients about – and address – HRSNs. When the pandemic began, his team quickly shifted to expand the program to all patients with COVID at Dell Seton Medical Center, a “safety net” hospital where the majority of patients are uninsured. They encouraged the use of a screening tool to identify HRSNs and then helped connect patients with community, public and private resources based on their needs.

“Of the first ten COVID patients at our hospital, nine identified as Black or Latino and eight spoke Spanish as their primary or preferred language,” Patel said, adding that four out of the ten also had concerns about losing their housing. “It was immediately clear there was a disproportionate effect of how the pandemic was playing out. We didn’t have a perfect model but we knew our patients were the ones hit the most significantly by the pandemic and we needed to connect them with resources.”

Fifty-six of the first 100 patients with COVID were screened and, of those, 64 per cent had relevant HRSNs. They all received targeted information and assistance for support.

In Toronto, a recent research study showed patients are not only comfortable with this data collection but appreciative – as long as the hospital can act on it. Victoria Davis, a master’s student at the University of Toronto working with The Upstream Lab at St. Michael’s Hospital, Unity Health Toronto, led a qualitative research project talking to general internal medicine (GIM) patients about their experiences and attitudes about being asked social determinants of health information. Many patients were 60 or older, typical of GIM units, and represented a range of race, gender and social needs.

“It was a very interesting finding – patients identified resource constraints as a barrier,” Davis said. “We talked to patients during COVID when they could see the burden hospitalizations were having on providers, so they naturally weren’t sure whether or not the hospital was capable of meaningfully and appropriately collecting this information and helping to address their needs.”

Other barriers were identified, including whether this data collection could lead to discrimination.

“There was a fear that patients would be judged or perceived differently by their provider if they find out they have difficulty making ends meet or couldn’t feed their children,” Davis said. “They were also really worried about staff gossiping about them. As part of this, they identified it’s essential to have a trusting relationship with their provider who would be asking these questions.”

Even patients who did not have unmet social needs recognized the importance of data collection if the hospital could follow through to help address concerns. Many patients suggested they wanted support navigating things like community resources – not just a list of places they could call, but someone to follow up with them and confirm they received access or provide support or alternate options if there was a significant wait time for recommended resources.

This is aligned with an increasing number of studies showing that patients recognize the role of their living circumstances on their health and medical care.

“The patients we talked to were able to identify that social needs were connected to their health and thought it could be important for their provider to understand their social and living circumstances and try to incorporate that into their care,” Davis said.

There’s a benefit for providers as well. When Patel and his team originally pitched the idea of introducing HRSN screening, they connected it to helping providers find more joy in their work.

“Many folks, regardless of what kind of work they do in the healthcare field, go into healthcare because they want to improve health and social conditions,” he said, “and so much of what we’re taught through medical, nursing and social work school is those sorts of things are not possible. When you send that patient with diabetes back to the street because you’re told that’s the only action you can take, that contributes to moral injury – when you know it’s a setup for disaster but you can’t help it. One of the things that came out of this is that having a community health worker on the case with a patient helps providers feel like they’re making a difference, not just putting Band-Aids on and hoping they don’t fall off.”

Moral injury can negatively impact patient outcomes and readmission rates, as well as lead to provider burnout.

“The solution has to be systemic – it’s not just about individual resilience,” Patel said. “If you’ve been through years of training and you worked through the pandemic, you’ve got resiliency. It’s not just telling folks to do yoga or meditate – we need to change our systems and structures and, unless we do that, we’re not addressing what causes moral injury.”

Both Patel and Davis are continuing this work, looking at various aspects of how to implement social needs screening, the best way to provide ongoing support and what it takes to build stronger, more trusting relationships both between providers and patients and between hospitals and community resources. Their work stems from an understanding that this is transformational – and necessary – change.

“We know that there are many different health inequities, and social determinants of health have the greatest impact on people’s health outcomes, on their morbidity and early mortality,” Davis said. “We also know many patients and individuals are struggling in society and don’t have the proper resources, knowledge or skills to help with that, so hospitals can bridge this gap to help improve public health, population health goals, more equitable healthcare and health outcomes.”

Patel agrees.

“We know we can help someone who is unhoused when they’re leaving the hospital, which is different from 2019 when we said that’s just not possible. We know it’s possible because we’ve done it and not only did cities not collapse but we prevented hundreds of thousands of cases of COVID and saved lives because of it. Now that we’re on this side of the pandemic, not only do we know this is the right thing to do and we know we can do it, how do we continue to build political movement to say our health system needs to put money and push towards this?” Patel said. “We need to transform the work we do to actually build a different model of healthcare so it’s not just improving the quality of what we’re doing – it’s shifting and transforming the model and changing the conversation about what is possible.”

System-level change starts by building quality improvement capacity at organizations – the more the culture reflects one of continuous improvement, the better chance for initiative success.

CQuIPS is excited to announce a new three-year partnership with St. Mary’s General Hospital to support this work. The partnership will see CQuIPS deliver multiple QI workshops to staff from across the hospital including information technology, lab and pharmacy, housekeeping and the emergency department. CQuIPS will also provide focused consultation on two key initiatives for St. Mary’s: patient ID band scan rate and time to inpatient bed.

Additionally, several St. Mary’s team members will participate in the CQuIPS’ certificate course and EQUIP program, developing advanced experts within the organization who can lead and support future QI initiatives.

“The idea behind our organizational QI capacity building is to support the hospital to lead in QI,” said Brian Wong, CQuIPS director. “We’re giving them all the tools they need to be successful in running change programs with one-on-one support from our team. We hope through this organizational capacity building work that we can contribute to building a more resilient healthcare system.”

Julie Nicholls, manager of quality and patient experience at St. Mary’s, said this partnership ties in perfectly to the hospital’s goals.

“Investing in education for staff is another way that St. Mary’s demonstrates our commitment to quality,” she said. “We are thrilled by the opportunity to provide such expertise in QI training for our staff. Our hope is that this will empower our team to build upon the excellent quality care they already provide by enhancing our collective QI capabilities with new ideas, tools and collaboration methods.”

It wasn’t until Mercedes Magaz began a quality improvement (QI) course that she realized she’d been doing QI her whole career. Though QI wasn’t the focus of her role as an internal medicine physician, she had always sought out opportunities to improve system-level issues.

“I realized in my role as a physician that my one-to-one interaction with patients was small compared to their whole journey across the healthcare system that’s often full of obstacles and barriers,” she said. “I started thinking I needed to use my clinical expertise to help the system improve.”

As CQuIPS’ new QI specialist, Magaz will have the opportunity to do exactly that.

Magaz is bringing with her more than a decade of experience including running the emergency department in one of Argentina’s best hospitals and supporting Sunnybrook’s infection prevention and control team’s QI efforts during the COVID-19 pandemic.

With CQuIPS, she will play a major role in supporting its organizational QI capacity building program, a service CQuIPS provides to train and coach teams within healthcare organizations to lead and contribute to successful QI initiatives.

“Mercedes has such a rich background to draw on for QI,” said Leahora Rotteau, CQuIPS program manager. “Her clinical knowledge and expertise are a huge asset because she understands some of the challenges healthcare organizations are facing in implementing QI work. We’re really lucky to have her on board.”

Magaz moved to Toronto from Argentina five years ago, and said she feels there is still more to learn about Canada’s healthcare system. She’s excited to flex the QI skills she began formally acquiring during her time in the Master of Health Science in Health Administration program at the University of Toronto.

“CQuIPS is the group you want to be in if you want to do quality improvement in Toronto so I am really happy and excited to be here,” she said. “I’m looking forward to diving into QI and putting QI into practice to play a part in helping people live better through these inconvenient times.”

CQuIPS is often referred to as a connector – bringing people, ideas and projects together. So it’s no surprise that Tara Burra, the Centre’s new education lead, wants to use her platform to build a better connection between quality improvement (QI) and mental health.

Burra is a psychiatrist at Mount Sinai Hospital, the first QI lead in her department and one of the creators of a new quality improvement, innovation and patient safety academic hub in the University of Toronto’s Department of Psychiatry. In addition to her clinical and QI background, she has experience revamping QI curriculum to be more effective and meaningful so clinicians have those skills embedded when they graduate.

“As trainees, we kind of get acculturated to the notion that there is a particular way of delivering care,” she said. “One of the really important parts of quality improvement and patient safety to is to question that – there could perhaps be alternative or better ways to accomplish the same end through an improvement that at the same time enhances patient experience and reduced costs. It’s also increasingly clear that it’s important we diligently address health equity through QI.”

As CQuIPS’ education lead, Burra will support the development, organization and scholarship of the Centre’s education programs with a specific focus on integrating health equity – one of CQuIPS’ two key themes – into all program aspects from the faculty, coaches and guest speakers to the content being delivered. Burra shared this is important to her as a mother of a child with a physical disability and as a woman of mixed race.

“One of the driving forces behind my interest in quality improvement and patient safety is having the direct experience of many healthcare journeys with my child,” she said. “We all contribute to ongoing improvement.”

Brian Wong, CQuIPS director, said Burra’s background makes her perfect for this position.

“As education lead, Tara will play a critical role in shaping how healthcare providers think about and approach QI,” he said. “We’re really excited to have her on board because she brings a unique perspective that complements the rest of our leadership team.”

Burra said she hopes the connections she helps form between CQuIPS and the mental health field will hopefully encourage more mental health practitioners to get involved in QI.

“One of the main reasons I was interested in this role is that the community for QI in mental health is thus far relatively small,” Burra said. “Mental health is a source of health inequity and I think it’s really important we have mental health leaders as part of the larger QI community and to elevate QIPS competency within my specialty.”

2021-22 Fellows. Top left to right: Katrina Piggott, Genevieve Bouchard-Fortier, Allison Brown, Natasha Gakhal. Bottom left to right: Beth Gamulka, Ashraf Kharrat, Sam Vaillancourt, Jennifer Wong.

Not everyone speaks the language of quality improvement (QI). This can make it difficult for people committed to QI work to find the mentorship needed to advance this work and pursue an improvement agenda in their organization. The Centre for Quality Improvement and Patient Safety (CQuIPS), whose purpose is to support and connect those working in QI, created a fellowship for exactly this reason: to bring people together with the ultimate goal of improving healthcare practices and outcomes.

“Although an individual might have formal training in QI, moving that knowledge into practice can be challenging,” said Joanne Goldman, CQuIPS scientist and Fellowship Director. “The CQuIPS Fellowship was established out of our goal to create a community for those who have been trained in QI and have dedicated time to do QI at their institutions, but are looking for continued learning and networking to strengthen their QI activities. The connections among and between the Fellows and CQuIPS have the possibility to lead to incredible results at organizations and the spread of impactful projects across our healthcare system.”

The Fellowship, now recruiting its next cohort for 2022-23, provides a myriad of resources for participants: a monthly learning session, an experienced QI mentor Fellows connect with regularly one-on-one, discussions and feedback on QI projects and opportunities to get involved at CQuIPS.

Jennifer Wong, a speech-language pathologist at Sunnybrook and one of the inaugural Fellows, said the connection with other fellows has been particularly rewarding.

“It’s amazing being part of a community of people who have a similar mindset about improvement and safety and who speak the same language,” she said. “It’s felt like all of our interactions – both with other Fellows and the facilitators – have come from a genuine place of connection and that’s been really meaningful to me.”

For Sam Vaillancourt, emergency physician and director of quality improvement for the emergency department at St. Michael’s, Unity Health Toronto and another inaugural Fellow, the education opportunity – from CQuIPS and his peer Fellows – has been a highlight.

“Even though I’m a little bit later in my career, I thought this might be interesting to go back to learning which, as you get further away from residency and everything, sometimes it can feel like the space for learning is gone,” he said. “A lot of people in our cohort have a fair bit of experience and have shared applied tips, difficulties and rewards. There’s a depth of engagement that I was hoping for and that turned out to be there which is really great.”

During their Fellowship, Wong and Vaillancourt have regularly shared updates on their projects with the other Fellows and their mentors. Wong’s main focus during the Fellowship has been on implementing a peer-to-peer vaccine champion program to support increased staff COVID vaccination rates at Sunnybrook.

“It’s been really helpful bouncing ideas off of Amanda,” she said of her mentor, Dr. Amanda Mayo, CQuIPS associate director for Sunnybrook. “And getting feedback from the other Fellows has been great too because we’re such a diverse group with different clinical and training backgrounds so that breeds opportunities for seeing things in new ways.”

Vaillancourt was paired with Patricia Trbovich, CQuIPS research and scholarship lead, who has supported him through his work on a patient-reported outcome measure questionnaire for patients leaving the emergency department.

“My mentor is quite exceptional,” he said. “It’s been really great to have some time with her every month and be able to share experiences, stories and difficulties as I’ve worked through this project.”

Fellows have had a significant role at CQuIPS: they supported the design, creation and launch of the virtual learning platform CQUIPS+ that now has almost 300 members; they’ve taken on leadership and teaching roles with our education programs; and they’ve collaborated with CQuIPS and its external partners including Choosing Wisely Canada and Canadian Blood Services.

“We’ve benefited from having these Fellows as part of the CQuIPS team just as much as they’ve benefited from being part of the Fellow group,” said Goldman. “We had such an incredible group for our first cohort – they’ve helped co-create this Fellowship to help make it the best possible experience for all future Fellows.”

Want to be a CQuIPS fellow? We are accepting applications for our second cohort until March 21 – learn more about eligibility and how to apply.