17-06-06 Ontwig Proceedings Final.Pdf

Engage. Align. Influence: Empowering Implementation

April 21 st, 2017 The Springer House Burlington, Ontario

Table of Contents

Symposium agenda Page 2 Message from the president Page 3 Health Quality Ontario (HQO): Wound Care Quality Standards (Process of Development and a Look at the Final Draft Standards) • Lacey Phillips Page 4 o Quality Standard v Clinical Practice Guideline v Professional Standards of Care Page 4 o What is distinct about Quality Standards? Page 5 o The Standards Development Process Page 6 o The finalized products of the Standards process Page 7 o HQO’s Current Scope Page 8 o HQO’s Anticipated Development Timeline Page 8 o Quality Statements for Pressure Injuries Page 9 • Lee Fairclough Page 10 o Implementation Planning Approach Page 10 o The Committee Page 10 o The Quality Standards Implementation Process Page 11 o Turning Recommendations into an Action Plan Page 11 o What does successful implementation involve? Page 12 o Implementation recommendations Page 12 o Putting the Plan into Action Page 12 o Quality standards implementation plan Page 13 o Ontario Quality Standards Committee Page 13 o Preliminary Implementation Feedback: Wound Care Quality Standards Page 13 • Terry Irwin o Successes and Gaps Page 14 o Key recommendations that have been heard to date Page 14 • Candace Tse o Breakout Session Review Page 15 o Pressure Injury Statements Page 17 • Sandra Pupatello o Reaching the Government – Message, Marketing & Medium Page 18 • OntWIG Annual General Meeting and Financial Statement Page 20 • OntWIG Sponsors Page 21

2017 Symposium Agenda

0830-0845 Welcome and program objectives 0845-0930 HEALTH QUALITY ONTARIO: Wound Care Quality Standards: Process of development and a look at the final draft statement

Lacey Phillips- Manager, Quality Standards Program HQO Terri Irwin- Director of Quality Standards at HQO

0930-1015 HEALTH QUALITY ONTARIO: Wound Care Quality Standards How can standards improve the quality of care in Ontario? Lee Fairclough, Vice President, Quality Improvement, HQO

1030-1130 Stakeholder feedback on the implementation of HQO Wound Care Quality

1130-1215 Dissemination of breakout group discussions to all delegates

1215-1315 Lunch & Networking

1315-1415 Influencing Government Relations Sandra Pupatello, Director of Business & Global Markets at Pricewaterhouse Cooper

1415-1530 Closing remarks, OntWIG Report

Message from the President

Valerie Winberg RN(EC), MN, NP-PHC, ENC(C), IIWCC

Valerie is a Primary Health Care Nurse Practitioner and Clinical Wound Specialist. Since graduating from the NP program at the University of Windsor in 2002, she has worked in Primary Care, Long-term Care and Emergency medicine. Currently, Valerie is the Executive Director/Clinical Lead NP at Twin Bridges Nurse Practitioner-Led Clinic in Sarnia ON, seeing clients for Primary Health Care as well as wound care referrals.

Wound care became a passion for Valerie as she started her NP career and began working with LTC nurses and residents. She has become an international speaker and educator in the wound care arena since. As an advocate for improved access to wound care for all, Valerie, was a founding member of the Ontario Wound Interest Group and is currently the President.

Dear Stakeholder and Woundcare Colleague;

The Ontario Woundcare Interest Group held the 7th Annual OntWIG Symposium on April 21, 2017. It is our distinct pleasure to present this document as an outcome of the Symposium which once again engaged a cross-section of clinicians, industry partners and interested stakeholders. The attendees engaged in lively breakout group discussion and interactive presentations with the keynote speakers.

The OntWIG executive team hopes that in sharing this proceedings document, we can continue the conversations that concern all of us regarding wound health policy. OntWIG is committed to pursuing the priority action items identified at the Annual Symposia through the input of the delegates, stakeholders and membership. Your ongoing commitment and contributions to the advancement of evidence-based wound health policy is exemplary.

Over the past year, many of the current OntWIG executive team and members have participated with Health Quality Ontario (HQO) to develop quality standards for wound care. This has been a formidable task for HQO and the interdisciplinary team gathered to review evidence, current literature and existing guidelines. It has also been an honor and a pleasure to be part of the process. The Symposium report provides you with a summary of this work and the next steps.

A special thanks our industry partners for their unrestricted educational grant support. These generous contributions allow OntWIG to continue to provide exceptional events at reasonable cost. Additionally, it is essential to acknowledge the tireless volunteer efforts of the executive team as they engage with membership regularly and have provided leadership to the working groups over this past year.

I look forward to the on-going work of OntWIG and greatly appreciate the contribution of all of you along the journey.

Valerie Winberg, RN(EC), MN, NP-PHC OntWIG President

Health Quality Ontario (HQO): Wound Care Quality Standards Process of Development and a Look at the Final Draft Standards

Lacey Phillips Lacey Phillips is a Manager within the Quality Standards program at Health Quality Ontario. In this role, she works with a dynamic and talented team to develop, implement, and evaluate evidence-based quality standards for the Ontario health system. Throughout 2016, she led the development of the three sets of wound care quality standards (diabetic foot ulcers, venous and mixed venous/arterial leg ulcers, and pressure injuries). Lacey has eight years of previous experience in the area of national and international health care quality standards development through her work at Accreditation Canada. She holds a Master of Allied Health Services Research from Dalhousie University.

Backgrounder To implement the quality standards program for wound care in Ontario is to follow a mandate set forth in the Excellent Care for All Act to promote health care that is supported by the best available scientific evidence. Then to make recommendations to health care organizations and other entities on standards of care in the health system based on or respecting clinical practice guidelines and protocols.

The birth of the quality standards program was designed to fulfill the mandate. Wound care has been identified as being among the key areas in which to develop quality standards. The implementation of the quality standards should be done in a way that places patients first. This process involves: • Supporting evidence-based quality improvement to address variations and gaps in care across different sectors (primary care, home care, acute care, LTC, etc.) that are caused by factors outside of patient choice • Providing patients and the public with relevant information, based on the best evidence, designed to help them understand exactly what to look for in seeking care • Understanding the data that demonstrates regional variations and contrasts in the quality of care that Ontarians are receiving in order to improve consistency across the province.

Quality Standard vs. Clinical Practice Guideline vs. Professional Standards of Care

Quality Standards are known to reference a smaller set of high-impact statements that describe optimal care where identified quality gaps are known to exist in Ontario. These statements are based on the best available evidence from the public and are designed to “raise the ceiling” for wound care and the overall health system.

Clinical Practice Guidelines often include conditional or equivocal recommendations that may or may not be specifically designed for or relevant to the Ontario health system.

Professional Standards of Care are typically mandatory practices that are intended to maintain the minimum expectations of practice for individual health care professionals.

What is distinct about Quality Standards? • They Must Be Concise: The standards contain 5-15 quality statements as opposed to the number that can appear in many clinical practice guidelines. • They Must Be Accessible: The standards allow for clinicians to know exactly what type of care they should be providing, as well as for patients to know exactly what type of care to expect. • They Must Be Measurable: Each quality statement is accompanied by one or more process indicators and if appropriate, structural indicators to understand the impact. • They Must Be Implementable: Associated quality improvement tools and resources specific to each quality standard are available to support the adoption of the quality standards.

There is an evolution from Quality Standards through Clinical practice guidelines to Professional Standards of Care. Quality standards are a smaller set of high-impact statements that describe optimal care where identified quality gaps exist. Clinical Practice Guidelines often include conditional or equivocal recommendations which may not be designed for the Ontario health system. Finally, professional standards of care are mandatory practices intended to maintain minimum expectations of practice for individual health care professionals.

The Standards Development Process HQO follows a structured Quality Standards Development Process clearly outlined in the following diagram:

The finalized products of the Standards process include:

1. Clinical guide – quality statements, backgrounds 2. Patient reference guide – summarizes statements for the public 3. Implementation and improvement – steps and recommendations 4. Information and data brief – slideshows 5. Indicator guide – technical specifications regarding indicator definitions

The long-term vision is to have more than 100 standards in the library available for easy access by healthcare providers and patients. To achieve this, the standards must evolve through an implementation process seamlessly as per the following diagram and explored more thoroughly in Lee Fairclough’s section to follow:

In summary, the pursuit of HQO’s mandate follows a structured path which ensures inclusion, thoroughness, and depth in the development and implementation of standards, including those for wound care.

HQO’s Current Scope

In understanding how HQO is approaching the issue of wound care standards, it is critical to understand the scope of their focus as presented in the illustration above. Lacey presented a development timeline presented below:

HQO’s Anticipated Development Timeline

Quality Statements for Pressure Injuries The statements for each type of wound have similar themes and are analyzed consistently (see the three boxes below). Statements that are specific to the management of each type of wound are highlighted in purple.

Implementation Planning Approach

Lee Fairclough Lee Fairclough is the Vice President, Quality Improvement at Health Quality Ontario (HQO). She is the former Vice President of Strategy, Knowledge Management & Delivery at the Canadian Partnership Against Cancer, a national organization responsible for improving cancer control in Canada, after initially joining their executive team to establish the newly created organization. Lee also served as the Director of the first Toronto Regional Cancer Program, as well as the Director of Informatics and the Clinical Research Unit at Princess Margaret Hospital.

Lee holds an undergraduate degree in Biology and Mathematics from McMaster University, and was trained as a Medical Radiation Technologist (MRT) through Sunnybrook Health Sciences Centre and the University of Waterloo. She has a Master of Health Science from the University of Toronto, where she was a recipient of the Robert Wood Johnson Investigator Award in Health Policy Research.

In May 2014, she was awarded the inaugural Louise Lemieux Charles Emerging Health Leaders award from the Society of Graduates.

In moving towards understanding the implementation phase of HQO’s mandate, let us briefly examine a few aspects of the process:

The Committee

The Committee is comprised of 31 different involved individuals, which include: • 2 lived experience advisers (1 patient, 1 caregiver) • 8 physicians • 13 nurses • 4 chiropodists • 1 dietitians • 2 physical therapists • 1 administrator

The Quality Standards Implementation Process:

Objectives for the Implementation Planning Process include: • Understand gaps between current care and the quality statements • Identify what health care professionals and the public need to use the quality standard • Identify potential partners and champions for implementation • Identify implementation approaches that have been effective

Each Standard requires two major activities: • Development of Recommendations for Adoption • Understanding the resources required to support implementation and improvement

Turning Recommendations into an Action Plan

What does successful implementation involve? • The characteristics of an ideal implementation guide should focus on content that is: 1. Relevant to practice 2. Available to patients 3. Strong and deliberate implementation • Patients and caregivers will know that the quality standards exist and can be utilized, equipped with the knowledge that enables them to: 1. Understand the meaning of these quality standards 2. Embed the quality standards in terms of planning methods and policy guiding • Establishing a clear understanding of gaps and barriers of adaptation, and the enablers to be resolved by: 1. Engaging with the committee for input 2. Engaging with the public for input 3. Engaging with front-line providers for input 4. Engaging with partners from successfully implemented programs • A 'system's plan' to describe what can be done by front-line providers, to describe policy recommendations that are to be passed onto the committee, and other roles for organizations to provide support • Formal recommendations for each standard to be passed to the committee for consideration for eventual public availability

Recommendations for Adoption • Readiness to address the gaps and hurdles, based on regional context • Use of levers to include the forging of contracts and quality improvement plans • Practical tools available to caregivers and patients to improve treatment • Role of communications clearly defined in order to send and receive instructions and feedback • Defining the roles for various partners to ensure clarity in implementation and care • Policy or regulatory implications to be understood in order to ensure smooth implementation • Assessment of resources in order to gauge the associated costs of implementation • Expected timings to initiate the recommendations established for clear expectations • Considerations for monitoring and evaluating to ensure continued success

Putting the Plan into Action Putting the plan into action through the use of the implementation guide entails strategies as to how teams can respond and the formation of available data for teams to refer to. Some characteristics of the implementation guide include:

• Structured as a 'system's plan' in order to describe what can be done by front-line providers to describe policy recommendations (to be passed onto the committee) and other roles for organizations to provide support • To include formal recommendations for each standard that will go to the committee for consideration for eventual public availability • Other examples of tools: 1. Clinical pathways 2. Decision aids 3. Order sets and methods to embed in systems of care 4. Auditing and feedback 5. Education and training

Quality standards Recommendations for Adoption • Each plan is unique for a given standard, as informed by QSAC, key stakeholders, and targeted structured interviews with front-line providers. The recommendations for adoption contain relevant evidence related to implementation with the purpose of reflecting a system-level plan in order to form the basis of formal recommendations for each standard through engagement of the Ontario Quality Standards Committee.

Ontario Quality Standards Committee § Subcommittee of the Board with the purpose to: • Provide guidance for Standard selection and weigh on the recommendations for adoption • Form a group of cross-sector leaders with the ability to share different and relevant perspectives in the industry • Funnel towards building a focus for the province's specific needs and to connect and coordinate existing programs in Ontario • Focus on cohesiveness and the advancement of specific issues • Recommend final standards and the overall recommendations to be referred to the Minister and the HQO Board

Preliminary Implementation Feedback: Wound Care Quality Standards • Feedback and suggestions from the public were passed on in order to improve the implementation process. Feedback was also gathered by serving and reaching out to front-line providers using Theoretical Domain's Framework Set of Questions.

Successes and gaps Terry Irwin Terry Irwin is a nurse leader and Director of the Quality Standards program at Health Quality Ontario. Quality standards are concise sets of easy to understand statements based on the best evidence and are developed for common clinical conditions in order to show opportunities for improvement in the Ontario Healthcare system. The goal is to have a library of 100+ standards over the next 5-7 years that are accessible to clinicians, health system decision makers, patients and the public. Terri’s previous experience includes front-line clinical management, professional practice within the acute care setting and standards development and consultation at the College of Nurses of Ontario. Key recommendations that have been heard to date • Access to offloading devices o Consider expanding public funding for offloading devices o Support surfaces and compression garments • Wound care data reporting o Specify the requirements to measure and report on wound care delivery outcomes o Document the adherence to standards through accountability mechanisms o Related suggestions: § Utilization contracts § Re-enforcement through HQO and Quality Improvement Plan Priorities • Access to inter-professional and specialty services o Ensure awareness of where teams exist and need to be developed o Consider developing LHIN-based interdisciplinary wound care teams o Improve access to inter-professional teams via technology to ensure patient-centred care is being delivered • Education and training o Provide learning and mentorship opportunities to support healthcare professionals acquiring the most updated competency and skills o Share specialty knowledge with nurses and clinicians to improve treatment • Information infrastructure o Leverage the use of existing information systems, such as GTA, RM&R and order sets to share data and information across care settings o Communication between providers o Address population-specific needs, mainly based on the regional disparities • Clinical pathways o Adapt existing clinical pathways and the integration of quality statements into daily care practice o Leverage outcome-based pathways from the home care sector in order to support the extension of clinical pathways into other sectors o Establish practicality • Accreditation o Identify opportunities to embed wound care quality standards into accreditation programs • Transitions of care o Alleviate the lack of a standardized method to document assessments and share care plans that is a barrier to managing transitions of care within and across sectors o Refer to how this how success is already being achieved in other areas with complex patients and connect these successful methods 14 Copyright ONTWIG April 21, 2017. All Rights Reserved

Break out Session – Membership feedback on the Health Quality Statements.

Candace Tse Candace Tse is a Quality Improvement Specialist at HQO with a focus on quality standard implementation and adoption. Candace is a physiotherapist by training and Lean Six Sigma, Green Belt certified. She holds a MHSc in Health Administration from the Institute of Health Policy, Management and Evaluation at the University of Toronto. Candace has held various positions in healthcare leadership spanning the fields of clinical care, quality improvement and project management.

Candace led this session which allowed participants to provide feedback for one of three sets of quality statements.

Quality Statement What is working well? What are some gaps What would help close the Are there practices or between current care and gaps in care? initiatives that could support care outlined in the quality (e.g. policy, tools, training) implementation of the statement? quality statement? Venous • Some CCAC’s are funding the • LTC – minimal to no access to • Order sets – perhaps with first pair of compression assessment and treatment medical directives for nurses stockings • Hospitals - inconsistent quality • Automated pre-populated • Front line RN’s performing of care forms ABPI’s • Home care- Cost of • LLU teams • Variety of options for equipment (hand held • Leg ulcer clubs compression and access dopplers and bp cuffs) • Define initial assessment • Increased quality of nursing • long delays in vascular lab timeline (monitor and address care for LLU access wait times for ABPI) • Communication of results • Listing of vascular labs takes too long available to do tests with wait • Clinical knowledge and times. decision making • Determine clinical • Access to maintenance qualifications for garments comprehensive assessment • Application support (donning • Public education campaign and doffing stockings) • Funding prevention • OT/PT assessment –falls risk, • ADP cognition and assistive devices • Application devices • MD comprehension of • OT/PT assessment compression systems, • Define responsibility for each technology, acute sector to support this management and population maintenance • HCP training qualification to • Competency for application of support out of hospital compression (health care patients professionals) • Point of care access Diabetic Foot • Pockets of well designed • Access to funding for • Public funding for access to programs that are cross-LHIN offloading is absent offloading supported • Access to HR – chiropody, • Public funding for appropriate • E.g., South West LHIN and Dietitians, mental health, NP, team members across the pockets in TC LHIN MD who are knowledgeable in province/sectors • Validated tools work when Patient life choices • MOH funding quality implemented • Cross sector comprehension standards • Tools/programs/teams and engagement (resistance • MOH funding for research on embedded into policy –works to change/best practice) studies of effectiveness of well. • Cross sector variation in devices • Where OBP was implemented access to best practice • Certification for wound care with same indicators/dash • Patients not on “any” pathway • Succession planning for board – worked well. • Clinical connect E-platforms wound care champions “not connecting” • Harmonize standards with the • Lack of certification for accreditation process and debridement other ‘mandatory’ metrics • Variations in funding of teams • Standardize the ideal at regional level Interdisciplinary team in each • Lack of prioritization for DFU LHIN at the LHIN level • Use technology to improve access and follow-up (eg telemedicine) • Connect and standardize “e” platforms to communicate

Pressure Injury Statements:

In the area of risk assessment/comprehensive assessment it is noted that sufficient tools are available for assessment and there has been a positive shift of focus towards prevention and providing the public and caregivers with increased awareness. • Some notable gaps include: o Lack of tools to assist patients and families to identify risk factors o Lack of critical thinking from the commission(?) to assess risk and carry out treatment o Fee for service funding models- inconsistency for access to assessment by different inter-professional groups o Lack of understanding of risk components and how to respond accordingly o Challenges in dealing with patient adherence issues o Lack of education for health care providers and patients for prevention and management o Helping clinicians identify learning needs o Equality for access to services, resources, and equipment based on regions of the province

In the area of patient education and self-management, patients have been more engaged in wanting to prevent pressure ulcers. Additionally, more organizations are providing resources for patient education and self-management and the availability of many devices to support patient education have been made available. Some notable gaps include: • Inconsistent approach to identify and explore the central concerns of patients • Lack of patient-friendly tools • Lack of documentation for patient education and response • Misalignment of data being reported • Lack of patient advocacy for assessment and re-assessment • Current funding model does not incentivize prevention • Inconsistent best practice uses by healthcare providers

Based on recurring themes to be reflected in standards documents, what has been working well include the availability of tools and guidelines as well as regional pockets of exemplary care within the province. In contrast, some common gaps that have been identified is the need for expanding access and education to providers and patients, the lack of public awareness, a shortage of engagement from public bodies and key decision makers, inadequate methods for transitions of care, the lack of a proper amount of data alignment for best interpretation, and insignificant political influence.

Reaching the government Sandra Pupatello As the Strategic Advisor for Industry, Global Markets & Public Sector for PriceWaterhouse Cooper (PwC) Canada, Sandra Pupatello puts her strategic thinking to work with businesses (private and public), throughout the supply network of most sectors, especially aerospace, automotive, energy, financial services, information communication technology, life sciences and manufacturing. As a skilled navigator of multiple stakeholder needs and a builder of profitable partnerships across multiple industries, Sandra is creating opportunities, driving growth and leading organizational transformation for PwC clients. Sandra served as an Ontario Cabinet Minister for eight years, six of those years as the Minister of Economic Development and Trade, and was a member of the Ontario Legislature for 16 years. Sandra has deep roots in the Windsor –Essex region, she was an MPP for Windsor West from 1995-2011 and has since been recognized for her headship in business, politics and community service. Now, with her understanding of the way government works, as well as her internationally recognized leadership skills, she supports PwC’s national and global business development initiatives, including providing advice on infrastructure and public-private partnerships.

Sandra is a strong advocate for Ontario's manufacturing sector, and is a Director of the Board at Martinrea International Inc. Canada's third largest auto parts supplier ,with facilities in many auto jurisdictions.

Sandra has a continuing interest in the energy sector having spent much time in her economic portfolio working with energy companies and was Chair of Hydro One, Canada's largest transmission company.

Message - be well-prepared • Understanding the message clearly when seeking influence and assistance from government servants; concise straightforward intentions • Knowing exactly how much money is to be sought, and where funds are to be directed Marketing – know the audience • Understanding exactly who is being marketed towards • Marketing the message according to the audience • Relationship building with the audience before seeking assistance o The importance of establishing a 'fan club' (patients and families) in order to provide public support for requests directed towards political officials Medium – understand communication methods • Government – messages with relevance about constituents (the 'fan club') • Hospitals – specific details regarding the financials, input, and output required • Crafting a cohesive and concise message that can be understood among all groups involved

Further considerations: • Understand MP/MPP perspective that primarily focuses on the particular fiscal year; long term thinking clouded by politics (express the immediacy of benefits rather than 5 years) • Be sharp and immediate and able to demonstrate the successful results of funding for when more funds will be requested in the future • Keep in correspondence – even if a politician changes roles, the individual may end up in another field or profession with capabilities to further assist 18 Copyright ONTWIG April 21, 2017. All Rights Reserved

• Keep a single database • Assigning a committee should keep the importance of government relationships in mind” • In writing to the Health Minister, letters should include: Content o “Will the standards save lives?” o “Are the standards critical?” o “Is the terminology too generic?” o The understanding that politicians are not necessarily health experts o Clarification of the difference between what ministers enact as legislation vs. guidelines o Adding to what the minister already has as guidelines, supported by 'fan club' o Let the families tell their stories regarding missed work o Let the ER staff tell their stories regarding frequency of dealing with the illnesses

Ontario Woundcare Interest Group Annual General Meeting

Financials and report from Valerie Winberg.

Organizational Goals: • Establish a network of inter-professional colleagues interested in advancing wound prevention and treatment across all health care sectors in Ontario. – OntWIG has participation from nursing (NP, RN, RPN), Registered Dietitians, Physiotherapist, Occupational Therapists, Chiropodists, Physicians – Continue to actively seek inter-professional members • Collectively lobby for and promote evidence-informed practice in wound prevention and treatment at the macro and meso levels of health care. – RNAO resolution – Lobbying Accreditation Canada – OHTAC submission • Increase public awareness of wound prevention and treatment as a major burden in health care. – Lobbying – Symposiums – Communication with membership • Synergize with other associations interested in wound health care quality improvement. – Stakeholder engagement – RNAO participation in BPG updates – WCA steering committee – CAWC involvement – Canadian Malnutrition Task Force

Financial statement: 11/01/15 – 10/31/16

Bank balance as of October 31, 2015 $33,421.99

Income Membership dues $11,210.00 Symposium fees $9,080.28 Other (vendor support) $11,000.00 Total: $31,290.28

Expenses Bell teleconferencing $832.88 Bank fees $50.26 Promotion $1237.11 Symposium costs $20,087.00 Executive expenses $11,537.55 Total: $33,744.80

Ontario Woundcare Interest Group Sponsors