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Response of the Department of Obstetrics & Gynaecology Response of the Department of Obstetrics & Gynaecology To 2014 External Review January 15, 2015 The Department, its faculty and staff, are grateful to the Dean and Faculty of Medicine 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 Family Medicine regarding a joint program to train Family physicians 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 Physician 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
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