Response of the Department of & To 2014 External Review January 15, 2015

The Department, its faculty and staff, are grateful to the Dean and Faculty of for prioritizing external reviews, and to the staff who organize and implement them. This is a valuable exercise and we are particularly grateful to the reviewers for donating their precious time and bringing their expertise to review our Department. The thoroughness of their investigation and the speediness of their report are appreciated. More importantly, they have provided sage advice and insights that will no doubt benefit the department and those we serve.

As a Department, we are proud of the achievements the committee found noteworthy. The Department worked hard over the last few years to build a strong administrative team that is now serving the Department well. This has allowed the department to pursue our academic mandates despite financially challenging times. Our education programs are good examples, and we were delighted that these were seen as strong and unique. The acknowledgements of our efforts to enlarge our endowment and develop novel means of funding the academic work of our faculty are also appreciated.

The reviewers clearly spent time to understand the nuances of our weaknesses and threats as well. Some of these stubborn problems are longstanding complex issues recalcitrant to change. For example, the reviewers note our lack of progress in achieving an Alternative Funding Plan, and repeatedly recommend the pursuit of an Academic Health Science Network (AHSN). We enthusiastically support this concept, and have even proposed a model to the Faculty of Medicine. Yet the scale of such an undertaking is beyond a single department, and will require a commitment from the Faculty of Medicine, University, and Health Authorities. Similarly, under the Heading, Implementation of Recommendations for Prior Review, the reviewers note “incomplete progress” on geographic and jurisdictional issues. We have to echo the sentiments of the previous Department Head in his response to the last review, where he noted that

“the remedy to these problems will not lie solely with the department, but requires a coordinated approach involving government, health authorities and hospital sites.”

While there is still work to do, significant progress has been made. There is one other important reflection from the response to the last External Review (2009) worth consideration due to its influence on the current review process. Specifically, the response to the 2009 External Review noted the expressed concern of multiple faculty members about the inclusion of the President of BC Women’s Hospital (BCWH), a member of the department, on the External Review Committee:

Departmental Response to 2014 External Review 1 UBC Department of Obstetrics & Gynaecology “There remains a strong perception that her presence may have filtered not only the comments from individuals making presentations to the panel but also the recommendations.”

We addressed a similar conflict during the formation of the present “External Review Committee” given its inclusion of the Vice President of BCWH, who is also a member of the department. This concern did not reflect apprehensions about her diligence or credibility, but similar concerns about how it influenced interviews and conclusions. As an example, BCWH is a very important site for the UBC Department, but the description of this relationship is perhaps unbalanced in parts of the review. For example, under the Heading, Health Care Delivery, it states:

“Although BC Women’s Hospital is a provincial resource and most faculty provide much of their clinical care, teaching and research at BCWH, the relationship with PHC and other geographic Health Authorities is unclear.”

This is not entirely accurate, as only 22% of our Clinician Educators and 33% of our Clinician Scientists have privileges at BCWH. This is especially important for the previously noted geographic and jurisdictional challenges, which are heavily influenced by tension between BCWH, other sites, health authorities and the UBC Department. The relationships of BCWH to PHC and VCH were previously defined within the 2005 Terms of Reference of the Perinatal Coordinating Council (PCC), although until this year, BCWH limited its own participation in the PCC. We feel that it is important to be aware of this filter in interpreting the report.

The review was favourably received by the department, although the Division Heads expressed disappointment that some of the issues they raised in discussions with the reviewers are not addressed in the report. The Reviewers identified a number of key areas for improvement and we will focus on these in our response. They include, health care delivery, communication and faculty engagement, research productivity, faculty and financial sustainability, leadership training and succession planning, and the role of the department head.

Health Care Delivery

With respect to health care delivery, the review acknowledges the department’s strategic plan to view our mandate in maternity education as extending beyond obstetrical services, and makes recommendations for addressing geographic and jurisdictional issues. With respect to the former, they encourage greater leadership from the Department in evaluating and supporting obstetrical care delivered by family practitioners and midwives. (Recommendation # 13) This is congruent with our strategic plan and the department has already begun planning with Midwifery around inter‐professional education and research, and with regarding a joint program to train Family in cesarean section. We have also sought collaboration in developing performance indicators that can be used across maternity disciplines. We are cautious in these endeavors to insure that collaborative projects are pursued as equal partners to avoid any perception of a controlling agenda.

This is an important consideration given the present provincial climate in maternity care. Our efforts to participate as equal partners in maternity care planning have been set back by the Departmental Response to 2014 External Review 2 UBC Department of Obstetrics & Gynaecology recent provincial Primary Maternity Action Plan that was developed with minimal obstetrical input even though obstetricians provide 55% of primary maternity care. Similarly, the UBC Department Head has been a voting member of the Steering Committee of the Perinatal Services BC since this provincial body for planning maternity care was formed in 2010. This role was dropped this year, as PHSA restructured PSBC under BCWH. Nevertheless, our commitment to being equal partners in improving maternity care remains and even gains importance in this climate.

In recom mendation 18, the reviewers endorse:

“formalizing an MOU between SPH and BCWH with respect to tertiary maternity care for mothers and their newborns and towards that end, provision of a more productive and sustainable working environment for MFM Sub­Specialists at St. Paul’s Hospital.”

Both efforts have been underway for several years. The principal obstacle to an MFM presence at SPH is the clinical service contract MFM has with BCWH. PHSA Compensation has interpreted this contract to geographically limit MFMs to BCWH, even though they are supposed to be a provincial resource, and the care at SPH is to compensate for the absence of clinical competencies at BCWH. We have worked around this obstacle, initially by using UBC academic funds to compensate an MFM provider and more recently through the good will of the MFM Division, but a sustainable solution will require BCWH and SPH to negotiate an MOU. Happily, the willingness on both sides to pursue an MOU is higher than ever before. As per the recommendation, the UBC Department will continue to advocate for a final solution.

Recomm endation 17 implores the Health Authorities and UBC to develop a:

“ more simplified leadership, management and accountability structure and clarify roles and responsibilities (particularly across the Lower Mainland) for high risk maternity care.”

We could not agree more, and this is yet another opportunity to extol the development of an AHSN that would facilitate such a solution. (Recommendation 19) Until then, clinical and academic leadership in the lower mainland is split between three entities, BCWH, PHC, and VCH.

Over the last few years, efforts to evolve towards a regional model have gained momentum within VCH and PHC, which may be the basis for the Review’s assertion that:

“The Department is most closely aligned with VCHA, through the Head’s appointment as VCHA Regional Head.”

Plans were underway to develop a Regional Head of Obstetrics & Gynaecology when the present UBC Department Head was hired, and consequently, the offer letter included appointments at BCWH, VCH and PHC as “Head of Obstetrics & Gynaecology”. The stated intent was to later combine the roles as one, with similar inter‐regional accountability as the PCC. This did happen for VCH and PHC, but the role was never defined at BCWH. In fact, the UBC Head while having a title has no role at BCWH other than membership on one committee focused on quality. (Recommendation 7) This has effectively marginalized the UBC Head at BCWH, which not only

Departmental Response to 2014 External Review 3 UBC Department of Obstetrics & Gynaecology has implications for planning high‐risk maternity care, but also for physician engagement at that site.

Physician Engagement and Communication

Physician engagement is an essential element of all departmental endeavors, whether it be finding clinician educators to deliver excellent educational programs or planning and optimizing research productivity. Recognizing its importance, the department has invested considerable energy to enhance it. The plan, initiated in 2011 included identification and recognition of clinician educators, developing a voice and representation of faculty members within the departmental hierarchy, better and more desired communication, and the creation of value for faculty members.

Towards identifying and recognizing clinician educators, the Department Head, Undergraduate Program Director, and Residency Director have travelled to all Health Authorities, including The Northern Health Authority, Island Health Authority, Interior Health Authority and Fraser Health Authority. Some of these trips were made together and others separately, but in all cases the department leaders visited faculty members in their hospitals with an open agenda. These were opportunities to assess the needs of faculty members, which led to the development of programs to provide value back to the faculty.

Such programs include the Fred Bryans Master Teacher Program, to help clinician educators develop better teaching skills, and the Continuing Surgical Education Program to allow them to expand their surgical repertoire through faculty mentoring. We developed a Grand Rounds series that are video linked to sites across the province twice weekly. We also reviewed all clinical appointments and promoted many clinician educators who had been at the Instructor level for many years.

Having established better contact with our clinician educators, we then worked to improve their representation in departmental business. The new governance structure achieved this by adding representatives to the Executive Committee from academic sites and health authorities. Division Heads also worked to involve members more in the business of the division, especially in the Division of General Obstetrics & Gynaecology. Rolling out responsibilities and accountabilities to the Division Heads was intended to support the role of the Division in representing its members and encourages better departmental engagement through the natural communities of practice represented by the divisions.

Communication is an essential component of physician engagement, and the department has made considerable efforts here as well. Prior to 2010, mass emails were the principal method of departmental communication. The impersonal nature of this approach made it inefficient. To counter this, we developed more direct email lists and tried to tailor emails to the audience. We also developed a departmental Twitter account and encouraged department members to follow the department. We use the Twitter account to disseminate information about events like rounds and research presentations, as well as highlighting and linking to research publications from the department and beyond. We saw the department’s Web site as a potential communication tool also and completely redesigned the Web site in 2011 to optimize its utility Departmental Response to 2014 External Review 4 UBC Department of Obstetrics & Gynaecology for faculty members. In 2014 we completed a second Web site redesign towards that end and to allow for more streamlined navigation. Specifically, we have used the Web site as means to provide useful information for faculty members, including information about events, research opportunities, and clinical tools. The intent is to encourage faculty members to seek out the web site for needed information, and engage their interest in other departmental issues, such as celebrating departmental news and success stories. The website is also intended as a Knowledge Translation tool, and links to donate to a variety of endowments are readily accessible.

We also use the D.A. Boyes meeting for faculty engagement. A large proportion of faculty members attend this annual CME meeting focused on clinical knowledge translation. Because of the strong attendance we schedule an in‐person, Province Wide meeting during the meeting. This has drawn larger and more engaged audiences then the previously poorly attended video linked meetings. It is worth noting the value of the D.A. Boyes meeting as a communication tool. Our Gynaecologic team conducted research implicating fallopian tubes as the source of a majority of epithelial . They hypothesized that removing fallopian tubes opportunistically during gynaecologic planned for other reasons, could significantly decrease ovarian cancer. This work was presented at the meeting, and was followed by a Province wide campaign to encourage gynaecologists to employ opportunistic salpingectomy. Subsequent research in a Provincial cancer database to determine the impact of this practice change on the incidence of ovarian cancer proved the hypothesis and has been widely recognized worldwide as the most promising approach to prevent this deadly disease. Without the D.A. Boyes meeting, the engagement of provincial gynaecologic surgeons would not have been possible.

In spite of our efforts and improvements to date in faculty engagement, we acknowledge the reviewers’ assessment that there is more opportunity for improvement. Because the Faculty leadership saw communication as an important issue, we incorporated it as an action item in our Strategic Plan. We are in the process of developing working groups to move the plan forward and will ensure that the membership of these groups encompasses a broad range of faculty and staff to provide insight into how best to achieve the goals. With respect to Recommendation 1, regarding a communication plan, we are conducting a needs assessment by surveying faculty and staff members on communication. Specifically, we hope to explore how they prefer to communicate with the department, so that we can tailor our efforts to best meet their needs.

In order to recognize and appreciate the contributions of all faculty members (Recommendation 4), the Department developed an Awards Committee in 2014 led by Dr. Lori Brotto, who is also the Departmental representative on the Faculty of Medicine Awards Committee. The Awards Committee is made up of tenured and clinical faculty, staff and students. Whereas awards recommendations were previously ad hoc, we developed a list of awards and can plan candidates well in advance of awards deadlines. The committee members’ work within their Divisions to identify nominees and to ensure the best recommendation is put forward.

Strategic planning is clearly an important area for faculty engagement. Towards that end, our strategic planning process began with direction to all Site Heads and Division Heads to hold strategic planning exercises within their groups. The results of these exercises were then brought to the Faculty Executive Strategic Planning retreat and formed the basis for the draft Strategic Plan. This draft Strategic Plan was then circulated to all faculty members for feedback Departmental Response to 2014 External Review 5 UBC Department of Obstetrics & Gynaecology and input. The fact that we did not receive feedback from faculty members is a testament to our need for better communication and further faculty engagement. Nevertheless, the strategic planning process took nearly a year to complete, and we do not feel that abandoning the present plan, which did seek wide involvement and buy in, will serve the department. (Recommendation 3). Instead, we are working to counter apathy through engaging faculty members and staff in the implementation of the Strategic Plan. We identified sponsors for each commitment who will be responsible for moving the plan forward. Striking diverse working groups with appropriate expertise to work on the individual deliverables operationalizes this implementation plan. The department’s Executive Coordinator is tasked with developing and monitoring time lines around actionable items to ensure progress.

Divisions play an important role in our faculty engagement plan, which highlights the importance of Division Heads as leaders. To support Division Heads in their roles (Recommendation 2), Division Heads meet regularly with the Associate Director and Budget Manager of the Faculty Finance Cluster. Similarly, our Faculty Development Officer is providing support and advice to the Division Heads on how they can grow their current endowments. They also meet regularly with the Department Head. These monthly meetings are intended to assist Division Heads in developing competency in financial management and fund raising, both for their own benefit and that of the Department. While these specific competencies are covered, building leadership capacity within the department would be well served by broader leadership training. (Recommendation 2 and 8)

Leadership and Succession Planning

The Department Head proposed a leadership program within the Department in 2014, both for faculty members in leadership positions and for those seeking them, but this program was postponed due to resistance from the Department leadership at BCWH, who were opposed to a department led program. As a stop gap the department turned to the UBC Academic Leadership Development Program (ALDP), and enrolled two of our new Division Heads in the Program. Their feedback is very positive, and our newest Division Head will enroll in the program starting in September 2015. While the ALDP is useful for Division Heads, more long term succession planning requires development of leadership competencies within junior faculty members. Unfortunately, the ALDP does not have the capacity for this. We are hopeful that the Faculty will develop a program focused on leadership development for junior faculty members, and we have offered to take an active role in planning that will make this a reality.

Our Postgraduate Training Program is also at work to develop effective faculty mentoring and career planning for residents. (Recommendation 10) There is a formal mentoring process in place for Residents. Through One45 access, residents can access a list of physicians who have volunteered to mentor residents. Unfortunately, this mentoring is presently poorly utilized. We will work to make residents more aware of this resource and tailor it to their needs including career planning. In terms of career planning a lot of that work is done by the Program Director when he meets with the residents twice a year.

Regarding the department’s 360 Review program (Recommendation 8) the Department believes that this is an important source of objective information for performance appraisal. The ability to absorb true constructive criticism from peers and those we lead and use it to evolve as a leader Departmental Response to 2014 External Review 6 UBC Department of Obstetrics & Gynaecology inspires accountability and transparency. This is why this tool is such a well‐established technique and why we believe it improves credibility and impartiality of the review while strengthening self‐awareness and self‐development.

We are grateful for the acknowledgement of our Department’s Anti Bullying Guideline as the first Departmental guideline within the Faculty of Medicine (Recommendation 9). As noted, there are overlapping policies within the Faculty of Medicine, and Health Authorities, which have Respectful Workplace Policies. The overall message that disrespectful and bullying behavior is inappropriate and cannot be tolerated is clear, and yet our Undergraduate Program has consistently received complaints from one of our main teaching sites. This is why, as a department, we made the effort to clearly define inappropriate behavior and to offer faculty, staff, and learners an additional option to report problematic behavior. The choice of the Administrative Manager as the point person both acknowledged the role as the most skilled position in Human Resource competencies, and offers alternatives to the FoM and Health Authority policies, which provide for reporting to Associate Dean of Equity and Professionalism or Site Head. We believe that offering the redundancy of reporting options outside the usual hierarchy is an indispensible component of the guideline. That said, we will codify this redundancy by adding Associate Dean of Equity and Professionalism, and Program and Site Heads as alternatives for reporting, although processing of the cases will remain with the Administrative Manager.

Research Productivity

The reviewers described our department’s research program as embodying the Faculty of strategic goals around research, and mentioned several “excellent high profile programs” including our research programs in ovarian cancer (OvCare), preeclampsia, basic science in , population health, and health services research. They noted “a good balance between basic scientists, translational scientists, and clinician investigators.” Yet at the same time they perceived an absence of strategic faculty leadership for research and recruitment. They recommended stabilization of the Graduate Program through new leadership (Recommendation 12), support for established research strengths (Recommendation 15), and the development of a new departmental position, the Research Director who would sit on the executive and chair the Research Committee (Recommendation 16). These are sound recommendations, and we make special note of the suggestion of adding a new executive position focused on research. At the same time, we want to correct the misperception that there is an absence of strategic planning with respect to research, as research considerations have been the primary driver of our recruitment plan over the last 4 years.

In 2010, the department’s research strengths; ovarian cancer, preeclampsia, basic science in reproductive medicine, gynaecologic infectious diseases, and perinatal epidemiology; were all silos with minimal coordination between clinical programs and other research areas. Moreover, many were marginally sustainable due to small size and aging scientists. The Graduate Program, a perfect example, was especially vulnerable given the death of one scientist and move of three senior scientists to retirement or administrative roles.

Our initial hires were focused on stabilizing the existing strengths. Dr. Jennifer Tomek (Hutcheon) and then Dr. Sarka Lisonkova were hired to expand the Perinatal Epidemiology Departmental Response to 2014 External Review 7 UBC Department of Obstetrics & Gynaecology Program, and Dr. Mohamed Bedaiwy to stabilize the Reproductive and portfolio. Within Gynaecologic Oncology, the development of the Chew Wei professorship allowed us to pursue a joint appointment for Dr. David Huntsman, while Dr. Janice Kwon and Dr. Gillian Hanley were recruited to broaden our Gynaecologic Oncology portfolio into endometrial cancer and health economics. Dr. Alex Beristain, a placental physiologist, was recruited to stabilize the basic science work in preeclampsia and renew the Graduate Program. We recruited Dr. Dan Rurak, an Emeritus Professor, to lead the Graduate program. His deliverables were expanding the mandate to include epidemiology, health services research, and health economics. His longstanding knowledge of the program and commitment to it served him well, and he has been very successful in achieving these goals. We have doubled the number of faculty members in the program and broadened its scope to include epidemiology, health services research, and health economics, while breaking down silos between scientists in the department. We are very grateful to Dr. Rurak for his service to the program and department.

Stabilizing the existing research strengths was a priority, but we had additional research goals, including seeking new funding sources, bridging the existing silos, and cultivating new areas of research, especially within areas of clinical strength and to support our educational goal of building a competency based curriculum. We had strong clinical programs in pelvic pain and endometriosis, , , urogynaecology, global health, and pediatric gynaecology. The creation of the Division of Gynaecologic Specialties was a first step towards achieving these goals through the provision of a home for the diverse groups. We hired Dr. Paul Yong, a Surgeon Scientist with a clinical interest in endometriosis and research interest in genomics. He provided the foundation for the research platforms of our Chronic Pelvic Pain program and Multi‐disciplinary Vulvodynia Program and set up his lab in collaboration with OvCare. We sought new salary funding for Dr. Regina Renner to develop an academic program in Family Planning and Dr. Sheona Mitchell in Global Health. These hires are based in the Vancouver Island Health Authority and Northern Health Authority respectfully, fulfilling our goal of expanding our research mission outside the Lower Mainland. Dr. Roxana Geoffrion won funding for educational research in competency‐based education, and we hired Dr Neeraj Mehra, a minimally invasive surgeon with a research focus in simulation, to build more capacity in educational research. We also pursued a joint recruitment of an educational researcher with the Center for Health Education Scholarship (Recommendation 14), although this was unsuccessful. Most recently, we hired Dr. Nicole Todd as a Clinician Scientist in Pediatric Gynaecology. Because of the absence of academic salary support, Drs. Todd and Mehra receive clinical support in lieu of salary through the University Group Practice Plan, allowing us to expand our academic mission despite limited academic funding. Dr. Money also expanded her research interests in Gynaecologic Infectious Disease through CIHR funding that allowed her to build the Vaginal Microbiome team, which includes collaborative research with the urogynaecology research team. She has also created links to the gynaecologic oncology research through the Center for Translational Research in Infections and Cancer and is seeking CFI Funding to expand this work.

These strategic research hires and efforts to foster links between existing and new programs have stabilized our strengths in ovarian cancer, preeclampsia, perinatal epidemiology, gynaecologic infectious disease, and reproductive basic sciences, while allowing us to develop new strengths. We arguably now have the strongest academic programs in Canada in urogynaecology, sexual medicine, pelvic pain, and family planning, and are developing research programs in aboriginal , global health, surgical education, and pediatric Departmental Response to 2014 External Review 8 UBC Department of Obstetrics & Gynaecology gynaecology. This is a very broad base of research with increasing links and efficiencies through economies of scale. Nevertheless, cultivating new areas of research while sustaining established strengths will be challenging in the present financial climate and underlines the need for continued development (Recommendation 20).

Dr. Rurak has agreed to remain the Director of the Graduate Program for 3 years, which will provide time for some of the more junior faculty in the program to build their careers before taking on the administrative role. (Recommendation 12) We are planning to pursue a new Executive position that will focus on implementation and optimization of the department’s research strategy.(Recommendation 16) One aspect of this role will be the oversight of the Research Committee, including further development of Research Bibliometrics, (Recommendation 5), that will allow accurate reporting of publications for both academic and clinical faculty (Recommendation 6) as well as resident and fellow publications. (Recommendation 11).

Faculty and Financial Sustainability

The Department’s Unit Specific Questions reflect our anxiety about our ability to maintain the academic mandate, given the financial realities of the Faculty of Medicine and Health Authorities. Our principal strategies have been not replacing retiring faculty members, seeking new sources and methods of funding academic work, and fundraising to increase the Department’s endowment. We appreciate the review’s recommendations to stay the course. As a department we strongly support the development of an Academic Health Science Network, and concur that this effort could contribute a richer and more sustainable academic faculty‐funding plan. We also share the perspective that this will require efforts at the level of the FoM. (Recommendation 19) In the meantime, we will continue to focus on development and work to build on our recent successes here. (Recommendation 20).

Role of the Department Head

In Recommendation 7, the Review recommends:

“Restructuring the operational and academic leadership portfolio to enable success in both the operational functions particularly quality of care and the academic nurturing and development.”

The committee clearly recognize the value provided by a nexus between clinical operations, educational programs and investigation and the challenges of coordinating these across multiple entities. The reviewers also acknowledge that such a restructuring would require the cooperation of multiple organizations, including the Faculty of Medicine, Vancouver Coastal Health Authority, Providence Health Care, and the Provincial Health Services Authority. As previously noted in the Health Care Delivery section, this cooperation has not flowed from all entities. Consequently, the department has worked to increase the effectiveness of the Department Head through available means.

A well‐organized and strong administrative staff has significantly improved the efficiency and effectiveness of administrative functions including the work of the Department Head. The efforts Departmental Response to 2014 External Review 9 UBC Department of Obstetrics & Gynaecology to push out responsibility and accountability to Division Heads, Site Heads, and Program Directors has also lightened the direct burden on the Department Head while creating an active Executive Committee to consider and prioritize the department’s issues. The same model of an Executive Committee comprised of Site Heads was also developed for the Regional Department of Obstetrics and Gynaecology for VCH/PHC. We have also linked administrative staff directly with the members of the Executive Committee to increase their effectiveness. The addition of a new Executive Committee position focused on research is an excellent recommendation that fits nicely in this model. (Recommendation 16) With this organizational structure the Department Head should be able to maintain effectiveness overseeing the UBC Department and Regional Department, and in fact, other departments including , and have adopted this model of dual responsibility.

Conclusion

The department is appreciative to the FoM for pursuing an External Review of our department. This process provides valuable insights into how the department is meeting its mandate as well as identifying opportunities to improve. We are most grateful to the Reviewers and receive their report with attentive and receptive obligation to use it constructively.

Departmental Response to 2014 External Review 10 UBC Department of Obstetrics & Gynaecology