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Susan Deering rides her bike to work, drives an electric vehicle and has solar panels on her roof. She considers herself to be very concerned about the environment and has modified the way her family makes purchases and lives to reflect that.

So in 2020, when the family doctor learned about how switching patients from metered dose inhalers (MDIs) to dry powder inhalers (DPIs) can have a positive environmental impact, she was stunned it was the first time she was hearing about it.

“I sort of felt a little bit cheated – like why didn’t I know about this before?” she said. “I thought there’s a serious education issue here at the very least, which means there’s an opportunity.”

MDIs are often prescribed to individuals with asthma or chronic obstructive pulmonary disease (COPD). But MDIs contain propellants called hydrofluorocarbons which become greenhouse gases when released from the inhaler and contribute to climate change. The impact of one MDI is estimated to be equal to driving a car about 300 kilometres.

Deering connected with Leslie Beyers, a community family physician, who led a QI project in her practice to systematically identify and switch appropriate patients using MDIs to DPIs, a more environmentally friendly option that has the same benefits for patients.

“The project was really about increasing patient knowledge,” said Beyers. “When I told my patients about the connection between MDIs and greenhouse emissions, they said that of course they would switch and, over a six-month period, well over 60 per cent of my patients did. I also wanted to look at how easy it was to adopt this into my own practice – I basically did this through opportunistic visits which meant it didn’t add any extra work.”

Climate and environmental change pose an accelerating and complex threat to human health, and the healthcare systems and practices that intend to protect and promote human health are themselves significant contributors to global carbon emissions. Recent research found that the healthcare system is responsible for almost five per cent of Canada’s carbon footprint.

From reducing food waste to switching to anesthetic gases with lower environmental impacts, transformative change to create low carbon, sustainable health systems is necessary — and ongoing.

Sustainability can be integrated directly into QI processes, as with a framework called SusQI developed by the Centre for Sustainable Healthcare in the UK, which incorporates sustainability as a domain of quality and embeds it throughout the processes of system analysis, improvement design and impact measurement. The framework goes beyond a carbon footprint analysis: it also evaluates environmental, financial and social costs (also known as the ‘triple bottom line’). Sustainability can and should become a target of quality improvement efforts: for example, QI initiatives that reduce unnecessary tests and treatments achieve the dual goal of improving quality while at the same time reducing the impact of the waste, energy use and other greenhouse gas emissions associated with those activities.

Inspired by this work, North York General Hospital (NYGH) wants to continue to be recognized as a leader in healthcare innovation by adding sustainability into their quality framework. The hospital added sustainability into its quality improvement plan two years ago allowing the hospital’s quality team to review proposed QI projects through a climate lens. These projects are governed by the organization’s Sustainability Committee allowing for accountability and further engagement on project’s they need to focus on. In addition to contributing to a greener planet, prioritizing sustainability also supports equity because vulnerable communities are more likely to be negatively impacted by climate change.

“The Centre for Sustainable Health System’s shared research that demonstrated hospitals are potentially one of the largest carbon producers in the community they exist in,” said Sean Molloy, NYGH’s Director of Quality, People Centered Care and Care Transitions. “And we thought, ‘We can’t be one of the largest carbon emitters in North York and say we’re advancing the health of the community” – that doesn’t make sense. Our patient experience partners are on board with this too – we are accountable to our community and they all agree we have to go in this direction. Not at the expense of providing good care, but by providing good care in a way that’s more sustainable.”

This move has led the NYGH QI team to support projects like reducing waste in the operating room – one simple change was asking patients to bring in a reusable bag to store their belongings while they were in surgery, rather than giving them a single use plastic bag, which Molloy said saw a 90 per cent uptake in the first test of change.

Marty Koyle has long had an interest in making the operating room leaner and greener. The former SickKids surgeon was frustrated about the number of surgical instruments coming into every single operation that often weren’t touched, yet then still had to be sterilized and repackaged for the next one.

So he ran a QI project.

Over a nine-month period, his team observed surgeons as they performed pediatric inguinal hernia repair (PIHR). They had two trays present: a larger one with all the possible instruments the surgeon might need, and a second much smaller tray that included only those instruments required for the majority of routine cases. They were instructed to use the smaller tray and only open the larger one if they needed an additional instrument from there.

Out of 52 PIHRs, only three required the larger tray be opened. The original larger tray had 96 instruments, whereas the smaller final tray had just 28.

“The project was a success – if you’re using fewer instruments, you’re processing less which means you’re using less energy, which reduces the waste and energy that contributes to climate change,” said Koyle. “We have to question what we do and not take things for granted; when you train in a system, you become part of the culture and adopt practices which isn’t bad but sometimes it prevents you from thinking about whether there’s a better way to do something.”

Sustainable QI work is expanding – and has taken on a new urgency.

The Sustainable Health System Community of Practice (CoP) was founded in 2020 by the Toronto Academic Health Science Network (TAHSN) and the University of Toronto’s Council of Health Sciences (CHS) to identify and spread best practices to help enable a more sustainable healthcare system. Their work is widely reflected across numerous resources and projects that span the healthcare system. The newly formed TAHSN QIPS CoP, which brings TAHSN hospitals and QIPS-focused groups, organizations and institutions to share knowledge and transform the healthcare system, is looking for ways to partner with the Sustainable Health System CoP and integrate sustainability into its work.

TAHSN and the CoP are among the partners who collaborated with CASCADES (Creating a Sustainable Canadian Health System in a Climate Crisis) on their first set of innovation playbooks, which provide ideas, examples and resources in step-by-step guides for innovation implementation and assessment of innovations aimed at reducing the carbon impacts of care. CASCADES is a national capacity-building initiative for climate action and awareness in healthcare funded by Environment and Climate Change Canada.

The Centre for Sustainable Health Systems (CSHS), which serves as secretariat for the CoP and as lead organizations for CASCADES, has recently launched a Greening ORs guidance document for improving the environmental sustainability of operating rooms, in collaboration with Best Practice in Surgery.

And Choosing Wisely Canada, the national organization focused on reducing unnecessary tests and treatments, opened their 2022 National Meeting with a talk about the synergy between resource stewardship and reducing healthcare’s carbon footprint.

All it takes to start is getting involved with one project.

Deering, Beyers and Koyle all highlighted additional projects they’re either already involved in or ideas they have related to reducing carbon emissions in their practices: improving recycling habits, reducing packaging, cutting down on food waste, adding a pollution index to hospital dashboards.

“If you think about the environmental crisis we’re in, it would be easy to hide in your bedroom and say, ‘I can’t do anything,’” said Beyers. “But if everyone can take little steps, not only will it help our collective mental health, but those little steps will also lead to a big difference.”

That’s what happened for Deering.

“When I heard about the significant impact that this seemingly insignificant little inhaler has, it was suddenly something I could do to actually make a material difference, and all I had to do was think differently about how I prescribe,” she said. “So now I’d give anyone the advice that if you see something, take a chance and dive right in – start having conversations because there are opportunities to do something meaningful.”

There are many potential harms children are exposed to during childhood – but unnecessary radiation doesn’t have to be one. That’s what Suzanne Beno and her colleagues believed as they set out to reduce the number of abdominal/pelvic CT scans ordered for children presenting to SickKids’ trauma bay. Their work – highlighting a significant drop with no adverse events – has just been published in the Canadian Journal of Emergency Medicine.

Beno was a learner in CQuIPS’ EQUIP program in 2017 when this work was starting. As the co-medical director of SickKids’ trauma program, Beno noticed there was an increasing and higher than usual level of abdominal/pelvic CT scans being ordered for children after trauma, yet a large proportion of the scans were coming back normal. An audit confirmed her suspicions – trauma teams were scanning more than published norms, which were already documented to be too high. With mentorship from EQUIP co-director Kaveh Shojania, Beno led the work to change that trend.

“We undertook this as a quality improvement (QI) initiative using the model for improvement with multiple PDSA cycles. We initially developed a trauma imaging diagnostic algorithm because we found people didn’t have a local guideline to help decide on when CT imaging was indicated,” she said. “We also developed just in time clinical decision support, making it clear that ‘mechanism of injury’ on its own was not an indication for CT and the child needed to meet specific criteria to justify getting an abdominal CT after trauma.”

Further PDSA cycles helped determine how teams used the guidelines and clinical decision support, then again once the hospital moved to an electronic medical record. While this was underway, the initiative was chosen as a hospital Choosing Wisely project, increasing visibility and awareness throughout SickKids.

The results were significant, dropping from a baseline of 26.8 per cent of children at very low risk of an intraabdominal injury having abdominal/pelvic CT scans obtained to less than seven per cent with the interventions in place – importantly, with no missed injuries. These results have been sustained and the initiative remains ongoing.

“Not only did this mean fewer children exposed to significant ionizing radiation – about 25-30 children per year,” she said, “it also resulted in numerous resource stewardship benefits.”

Beno credits the EQUIP program as a factor in the project’s success.

“Kaveh helped refine our AIM statement and proposal and looked at it from a pragmatic and academic stance,” she said. “EQUIP had a huge role in making sure this project launched and was successful.”

Beno hasn’t slowed down since the CT scanning project wrapped – her team has been involved in other QI initiatives, including instituting a new massive hemorrhage protocol and trauma video review, and she’s about to begin working on a project to reduce non-value added time in the trauma room.

“Trauma is ripe for process performance improvement and QI,” she said. “It’s about understanding that things aren’t stagnant – the field is constantly moving forward, and we need to continually improve our processes to optimize patient outcomes. At the same time, QI is also about job fulfilment and satisfaction – it helps us make sure we’re doing the best job that we can in a complex and challenging environment.”

Over the course of the COVID pandemic, CQuIPS members and alumni have stepped up in significant ways to support their colleagues, patients and communities. In this special series, we highlight the work they’ve done towards a more equitable recovery.

Dr. Beth Gamulka is a paediatrician at SickKids, EQUIP graduate and current CQuIPS Improvement Fellow. Early in 2021, she received an email from her chief medical officer asking for physicians to add their name to a list if they were interested in supporting vaccine clinics if and when an opportunity arose. Not only did Gamulka add her name, she, along with a colleague, put up her hand to lead the coordination of connecting SickKids physicians with clinics in need of staffing. That’s how she found herself with a list of more than 140 physicians.

“We went hospital to hospital in the GTA to find out if anyone needed physicians to help,” she said. “We urgently got 100 physicians temporary privileges to the Scarborough Health Network to help staff pop-up clinics in hot spots, we shared our list with Women’s College Hospital so our staff could vaccinate at their mobile clinics, and we had people supporting at Unity Health. We also helped staff special clinics for high risk SickKids patients – over two weekends we vaccinated more than 700 youth who had transplants or were on chemotherapy and what was nice was some of them had their own physicians give them the vaccine.”

Gamulka herself has been doing eight to ten vaccine clinics a month, describing the feeling there as “pandemic Disney.”

“These clinics are the happiest places on earth – just the vibe,” she said. “As much as we physicians think we’re all doing such a good thing, when you go to a clinic, you get more out of it than you get in – it’s a wellness exercise.”

In addition to being the lead source of information for many of her fellow physicians, Gamulka said the role brought her into contact with new colleagues.

“I’ve worked at SickKids for many, many years and there were people I’ve never met before suddenly volunteering and exchanging emails,” she said. “It was nice to see people coming together – you go to these clinics and you have a psychiatrist and anesthetist vaccinating together and they probably would have never otherwise run into each other.”

Dr. Tara Kiran has spent the last year and a half supporting family physicians to learn from each other to provide the best possible care during COVID-19. A family doctor at St. Michael’s Hospital, the Fidani Chair of Improvement and Innovation and the Vice Chair of Quality and Innovation at the Department of Family and Community Medicine (DFCM) at the University of Toronto, and CQuIPS core member, Kiran saw an opportunity early in the pandemic to create a safe space where people could bring questions, share best practices and learn from colleagues.

Under Kiran’s leadership, the DFCM and the Ontario College of Family Physicians (OCFP) collaborated to host a biweekly Community of Practice for family physicians. Sessions feature family doctors from across the province who share their expertise and innovations. Once the COVID-19 vaccination campaign began, the sessions grew in popularity and scope with some now featuring specialists who can help family physicians stay up to date with rapidly evolving evidence. All sessions are recorded and shared on the DCFM quality and innovation website and accredited – even after the fact – so those viewing can get continuing professional development (CPD) credits.

With 600 to 800 family doctors present at each session, the Community of Practice become a safe space for sharing updates and collaborating.

“We’ve gotten so much positive feedback – people turn to it as a source of information so it’s been great to be able to provide that consistency during this chaotic time,” she said. “For me personally, the sessions enable a connection with my colleagues and allow me to constantly keep learning about the latest evidence. I’ve enjoyed putting it together and connecting meaningfully with others.”

Kiran also spearheaded an effort with the DFCM team and OCFP to create a series of e-learning modules for primary care clinicians about COVID vaccination, which include resources on vaccine safety and efficacy, the role of primary care, building vaccine confidence and more. Constantly being updated, the modules are meant to be revisited to locate resources and stay on top of new updates. To date, more than 2,600 healthcare practitioners have registered for access.

“As many smart people have said, if we want to improve practice and outcomes, we have to link it to physician and practitioner learning,” she said. “Linking quality improvement and CPD is something I’ve been working on – even prior to the pandemic – and I think our challenge will be to continue to deliver CPD that simultaneously supports physicians in directly improving practice in a measurable way and is also grounded in patient and community needs.”

Kiran has also taken on a lead role of supporting patients during the pandemic, recognizing that many have been challenged to keep up with rapidly changing guidance. Kiran has been a regular presence in Toronto and provincial media, breaking down how changes affect everyday people and providing a reassuring voice. She’s also helped host patient town halls within her Family Health Team and developed informational handouts about vaccine safety.

“The pandemic has demonstrated the importance of providing clear, direct communication to the public which isn’t something we as physicians are necessarily schooled or incentivized to do,” she said. “I feel like this has been a good opportunity to hone these skills. There’s a huge interest in health and healthcare because of COVID and I think it would be great to leverage that beyond the pandemic.”

Over the course of the COVID pandemic, CQuIPS members and alumni have stepped up in significant ways to support their colleagues, patients and communities. In this special series, we highlight the work they’ve done towards a more equitable recovery.

When Sunnybrook began planning vaccine rollout to staff, Dr. Adina Weinerman, Medical Director of Quality and Patient Safety at Sunnybrook and CQuIPS Certificate Course Co-Director, immediately thought about staff who would be hesitant.

“From everything I had been reading and our data from previous flu vaccine campaigns, I knew there would be staff who would not be interested in getting vaccinated – even those at very high risk based on where they live, how they get to work or their specific job,” she said. “Senior leadership was appropriately focused on the logistics of efficiently getting people vaccinated who immediately wanted the vaccine so Brigette Hales and I decided to work on a strategy for those who might need more information or time to understand the benefits.”

Working with Hales, Director of Quality and Patient Safety at Sunnybrook, Weinerman ran a mutli-pronged campaign that included recruiting more than 70 peer champions who could answer questions for their colleagues, creating frequently asked questions informed by qualitative interviews on hesitations identified by staff, and leading small group huddles in areas where vaccine uptake was low. They also partnered with the President’s Anti-Racism Task Force (PART) at Sunnybrook to inform a virtual session specifically for Black staff on the impact of COVID and vaccination.

“We knew objectively that COVID disproportionately affected Black communities in Toronto and Ontario and there’s a history of racism in vaccine creation and rollout,” she said, “so there was a real reason we thought it was important to reach out. It wasn’t that we anticipated more hesitancy than in other staff, but we knew there might be unique concerns and considerations. PART led the forum with an all-Black staff panel which included physicians, nurses and health professionals.”

Above and beyond all of that, Weinerman and Hales created an email address where staff could send their individual questions related to COVID – and the two personally responded to hundreds of emails.

“We really tried to take an approach where we understood that for many people, this is layered and deep and they have a lot of personal conflict related to vaccines. There was a ton of information everywhere but also a lot of false information so we wanted to be a source of impartial, truthful information so that people could make the best decision for themselves,” she said. “All along, people had great questions – it was clear they were reading about it on their own. It was completely worth it.”

As a result of their efforts, Sunnybrook reached an over 80 per cent staff vaccination rate in the spring – higher than the 70 per cent seen most years for flu vaccine.

Jennifer Wong deserves credit for that number too. A speech-language pathologist (SLP) at Sunnybrook and CQuIPS Improvement Fellow, she took on the task of leading staff vaccination confidence efforts in the Veterans Centre where she’s worked for more than a decade, home to some of the hospital’s most vulnerable patients.

“That’s our division of long-term and palliative care,” she said. “We’ve certainly seen in the news the impact COVID has had in this sector over the pandemic, so that was an area we really wanted to target, knowing the high risk.”

With the vast majority of residents getting vaccinated early in 2021, Wong turned to staff. Working with patient care managers and using her own knowledge of the centre, she recruited staff champions, bringing them together for weekly huddles to share latest updates, dispel any circulating myths and collaborate on strategies for challenging conversations. Champions were encouraged to recruit others as well so there was a network of respected individuals who could support their colleagues.

“We know from the literature that in terms of battling vaccine hesitancy and building vaccine confidence, being able to talk to someone who’s trusted and has a personal and vested interest in you is impactful,” she said. “And then everything we did after that was based on feedback we were getting from champions – we really tried to be responsive to what we were hearing from the front line.”

Other strategies included making it easier for people to book vaccines, as many staff don’t regularly check email; Wong and her team set up a booking table in the lobby and registered people on the spot in their areas. They also regularly visited units that needed additional support for walk-throughs or huddles to answer questions.

“Within the Veteran’s Centre, there are 15 patient care units and close to 500 beds so the staffing is massive,” she said. “We knew our small army couldn’t tackle everywhere so we used a data-driven approach to find out which areas needed the most attention and focus.”

Always focused on quality improvement, the next steps for Wong include collecting qualitative data on the efforts, identifying what enabled champions to be effective and what further barriers they encountered so they can be prepared for the next vaccine campaign.

“One of the main things I’ve drawn from this is that it’s important to understand how people are connected to each other and relate to each other,” she said. “It’s been a really great opportunity to use both QI and soft skills; that’s always been something that’s really interested me – it’s one thing to engage stakeholders, it’s another to create behaviour change. And it might just be my SLP background, but it’s important to recognize that how you say things is equally as important as what you say.”

Over the course of the COVID pandemic, CQuIPS members and alumni have stepped up in significant ways to support their colleagues, patients and communities. In this special series, we highlight the work they’ve done towards a more equitable recovery. 

It was while responding to a COVID outbreak at St. John’s Rehab that Dr. Amanda Mayo, physiatrist at St. John’s Rehab and CQuIPS Associate Director, realized her team needed to do more to protect their patients. Lower on the priority scale than others for receiving the vaccine, rehab patients both on site and coming in for appointments were at high risk for contracting the virus.

“A lot of our patients have multiple comorbidities and regular home care – they can’t physically isolate from their personal support workers (PSWs) or nurses coming in and out of their home to provide care,” she said. “I had one patient who is an amputee who had ten PSWs visiting her apartment every week. Many patients I talked to were scared.”

Mayo, along with others in the Division of Physiatry, advocated for rehab patients to be moved up the priority list. As a result, vaccines were distributed to patients and staff on site early in 2021. Shortly after, the team began offering vaccines to outpatients as well, up to 12 appointments every Tuesday afternoon to individuals coming in for treatment and their essential caregiver family members.

“We were basically trying to vaccinate anyone who couldn’t vaccinate in the community,” Mayo said. “There are a lot of barriers for this patient population – for many pop-up clinics, you have to stand for long periods of time, and even just booking an appointment could be challenging for someone who doesn’t have internet, or who has poor eyesight, poor finger dexterity or may not use traditional technology. It was an access issue.”

Mayo said she was grateful to be able to help answer one of the biggest questions she was hearing from patients about how and where they could book their vaccines.

“It’s been fantastic because for some patients, the only time they might leave their home is to go to therapy for medical appointments. They were really happy to come to St. John’s because they’re familiar with the site and they have Wheel-Trans transportation booked for the site, so it just made things so much easier.”

Early on in the vaccine rollout, another major barrier for many was that an OHIP card was needed to book an appointment. Jacqueline Follis, graduate of the CQuIPS certificate course, led the establishment of a vaccine clinic through Women’s College Hospital on College St. that specifically addressed this, connecting with community partners to book clients directly in.

“It’s really been about supporting our clients who face barriers to getting their vaccine,” said Follis. “My proudest moment was the Saturday where we saw 722 people come through – thirty percent of those were individuals who were uninsured, marginally housed or underhoused.”

The team has also hosted days for specific priority groups, including for youth 12 and older from French language schools (the site is fully bilingual) and one just for people who are uninsured.

Follis is an advanced practice nurse by training – it was during the pandemic that she was asked to step into the role of leader, first of the hospital’s COVID assessment centre and then the vaccine clinic. Prior to the College St. location opening its doors, Follis helped lead a three-week campaign visiting congregate living sites to vaccinate staff, clients and essential caregivers.

“I’ve been using my CQuIPS quality knowledge, medical background as a nurse and operational experience from the last year to answer the question of how we can better support our clients who face barriers,” she said. “I’m really proud of the opportunity I was given, that I could use my background and skillset to pull everything together. I’m just so grateful.”