Issue 3 | January 20 2021
Monthly Bulletin of the Alliance's Learning Health System
QI @ CSC du Témiskaming
New Alliance Publications
Alliance Research Roundup
Learning Events & Opportunities
New Tools &
Get Involved: Research & Sharing
Learning in Leadership: QI at the CSC du Témiskaming 
For over 15 years, the Centre de santé communautaire (CSC) du Témiskaming has been using practice-based data to drive quality improvement, but the way they do this has been constantly evolving. Jocelyne Maxwell, the CSC’s Executive Director, has come to recognize the importance of an overlooked element: willingness on the part of leaders to acknowledge and learn from failure.

The CSC’s QI journey has proceeded in baby steps. It began in the late 2000s, when Maxwell received training from the Canadian Foundation for Healthcare Improvement (CFHI) – then known as the Canadian Health Services Research Foundation – about using data to inform management decisions. Excited about this “new world,” Maxwell and her leadership team developed a 15-page dashboard and incorporated it into their strategic planning. But there was little improvement in the numbers, and they were left scratching their heads.

The next step came with the introduction of Quality Improvement Plans (QIPs), which required organizations to document not only their goals, but their strategies for achieving them. This sparked in-depth conversations with their board about QI, and the board brought in outside experts to teach them. When they went through the accreditation process, reviewers noted that the CSC’s board “got” QI in a way that few others do. The CSC made quick gains in priority indicators, such as cancer screening rates, but these tended to be short-lived.

A transformational change began after Maxwell and other leaders at the CSC took a Lean training course from the Canadian Centre for Accreditation (CCA). Being accustomed to taking a high-level view of organizational processes, she did not relate, at first, to its practical, ground-level approach. However, through conversations with staff, she came to realize that the training might equip them for meaningful QI. When asked, they were unanimous that it would, so they the whole staff received Lean White Belt training. More recently, she offered the opportunity for a smaller number of staff – approximately 20% – to take Yellow Belt training, and nearly 80% of them wanted in. “All of a sudden,” Maxwell says, “they had tools, and QI made sense.” Since then, seven staff have gone on to get Green Belts.

As she continued her conversations with the Lean trainers around what QI means at an organizational level, Maxwell realized that the focus needed to shift from numerical targets to sustainable processes. As a team, they’re still learning to build the tools and frameworks to support their QI journey. “We’re at the infancy stage,” she says, “not because we haven’t been thinking about QI for a long time, but because as a leadership team, we’ve stepped back to reflect on what’s happening and how we’re using data in the organization.”

By investing in training for the whole team and encouraging all of them to look critically at the ways they work, the CSC du Temiskaming has created an environment for leaders to emerge in each team and become coaches. The CSC is now setting QI priorities at an organizational level, developing a concise strategic plan focused on a smaller number of indicators, and building the capacity to attain their targets in a way that is sustainable. “In the past,” she says, “we were so zealous about demonstrating how well we were doing that we focused on dashboards instead of on learning. We put so many indicators into those dashboards, but we didn’t acknowledge that our capacity was limited.”
Two New Publications from #AllianceResearch
2021 has just begun, and already two new, peer-reviewed studies have already been published by the Alliance research team and their research partners.
First Peer-Reviewed Canadian Study on Social Prescribing
On January 5, a qualitative evaluation of Rx: Community, the Alliance's Social Prescribing Pilot, was published in BJGP Open. It shows that participants' positive experiences align with a theory of motivation known as Self-Determination Theory (SDT), a clue to how the program works to improve health outcomes.

According to SDT, self-determination motivates people to make lasting positive changes and experience better mental well-being. The four dimensions of self-determination are Autonomy (control over one's own life), Relatedness (close, affectionate relationships), Competence (being capable and effective), and Beneficience (making a positive difference). Participants in Rx: Community - especially those who were health champions - experienced improvement in all four of these dimensions.

By applying an established psychological framework to understanding how social prescribing works, we can develop evidence-informed guidelines and goals for other organizations who want to develop their own social prescribing programs. This can also help direct future research into what social prescriptions work best for which clients. Sara Bhatti, the Alliance's Research & Policy Analyst and one of the study investigators, notes that one of the most striking findings for her was "how asking clients, Would you be interested in this? instead of I think you should do this is a key part of what makes social prescribing so powerful."

Using Self-Determination theory to understand the social prescribing process: a qualitative study. Sara Bhatti, Jennifer Rayner, Andrew D. Pinto, Kate Mulligan, and Donald C. Cole. BJGP Open, January 5, 2021.
Measuring COVID's Impact on People Experiencing Homelessness
On January 11, a quantitative paper that measures the inequitable impacts of COVID-19 on the health outcomes of people experiencing homelessness was published in CMAJ Open. Using linked administrative data, the researchers provided tangible evidence to support what many people suspected: people with a recent history of homelessness are particularly vulnerable to COVID-19 infection and complications.

The study compared people who had recently experienced homelessness to others living in the community. Those who had been homeless were more likely than others to be tested for COVID-19 and to have a positive test result. The researchers also compared the outcomes for the two groups after receiving a positive test result. During the peak of the first wave (March 14-June 16, 2020), those who had recently experienced homelessness were more likely to be admitted to hospital, over 10 times more likely to require intensive care, and over 5 times more likely to die within three weeks.

Dr. Jennifer Rayner, the Alliance's Director of Research & Evaluation, notes that, sadly, "This study demonstrates what we already know - that gross inequities exist in Ontario, and that health, poverty, and housing are linked. We need to stop being surprised by this data and start acting on it by providing tailored care for people to truly reduce health disparities."

Testing, infection and complication rates of COVID-19 among people with a recent history of homelessness in Ontario, Canada: a retrospective cohort study. Lucie Richard, Richard Booth, Jennifer Rayner, Kristin K. Clemens, Cheryl Forchuk, and Salimah Z. Shariff. CMAJ Open, January 11, 2021.

Alliance Research Roundup:
What else is our research team studying?
In the November issue of EPIC News, we shared a list of all the Alliance research studies related to the lessons of COVID-19. Of course, that's not all we're doing. Research projects that began before the pandemic are still underway. The social prescribing study described above was one of them. Here is a list of others.

All of these studies are externally funded and involve one or more partners. Jennifer Rayner, our Director of Research & Evaluation, is a co-lead investigator or co-investigator on each of them.
Short, medium, and long-term effectiveness of interdisciplinary teams and other primary care reforms in Ontario: Examines the effectiveness of different models of primary care, including costs.
Spread and Sustainability of Integrated Models of Team-Based Care for the Management of Chronic Obstructive Pulmonary Disease – A multi-case study: Explores how integrated models of team-based care spread from one context to another and how to sustain the benefits of team-based care for people living with COPD.
Health Outcomes and the Association with Primary Care Use Following Transfer to Adult Healthcare Services amongst Young People with Neurologic Impairment and Technology Dependence in Ontario: Describes mortality rate and acute care use during early adulthood (20-26 years), and compares primary care use during the pre-transfer (16-18 years) and post-transfer (18-20 years) periods for young adults who live with neurologic impairment and depend on assistive technology.
Primary Care for Individuals with Severe Mental Illness (PRiSMI): Identifies how primary care can better support people with severe mental illness in Ontario and BC, using population data.
Advancing knowledge of homelessness: Expanding use of administrative datasets in Ontario: Will enhance infrastructure for sharing and using administrative healthcare data about homelessness. The goal is to develop an inventory in accessible language profiling social service, community, and survey databases in Ontario with potential to identify people experiencing homelessness.
Optimizing Canada's Healthcare for Refugees: Examines health outcomes among newcomer refugees by refugee-sponsorship model (Government, Private, or blended) as well as between distinct large refugee cohorts (e.g. Syrian, Iraqi, Bhutanese). Will provide socio-demographic descriptions and shed light on the interplay between resettlement model and health and social outcomes.
Diabetes Action Canada – Project OPENA multi-pronged suite of studies. One element is development of patient- and research-informed innovations in equitable health care delivery designed to prevent diabetes and its complications.
Learning Events and Opportunities
Thursday, January 21, 1:00-2:30 pm: The health equity impacts of a changing climate, Part 1: From Assessment to Action (webinar). From the National Collaborating Centre for Determinants of Health and Health Canada. Learn practical ways to support highly-impacted communities as they build their capacity to adapt to a changing climate. In English with simultaneous French interpretation.

Friday, January 22, 8:15-9:15 am: Panel and discussion on COVID vaccines – ethics and politics of uptake and distribution. Watch for details here. Part of the
COVID-19 Virtual Community Rounds from the Centre for Wise Practices in Indigenous Health at Women's College Hospital.
Friday, January 22, 12:00-1:30 pm: The role of systematic reviews in intervention research. Learn how to conduct systematic reviews (the gold standard for knowledge synthesis) for a variety of research and practice questions and methods, and use your findings to inform health and social care programming and policy. Presented by the MAP Centre for Urban Health Solutions
Monday, January 25 - Wednesday, January 27: Free workshop series about the health impacts of low-carbon and nature-based infrastructure, from the Smart Prosperity Institute Workshop the first of a two-part series on Health & Infrastructure.
Wednesday, February 17: ICES Winter Forum: Data and Analytics in Critical Times. This free, one-day virtual research symposium is focused on using data and analytics to support pandemic planning and response.
New Tools & Resources
Ontario Community Health Profiles Partnership (OCHPP) makes high-quality, area-specific, health-related data available to everyone in the form of maps, tables, and charts. New data has been added about hypertension, visits for mental health and addiction care, COPD, and other chronic conditions.

IPAC+ Resource Library is a repository of information on infection prevention & control (IPAC) practices in long-term care facilities and retirement homes, led by the Knowledge Translation Program at St. Michael's Hospital. For more information about how to access IPAC+, email [email protected].
National Overdose Response Service (NORS) is a hotline that provides remote peer support and company for people while they are using drugs, to reduce overdose risk that comes from using alone. NORS has a non-judgemental, harm-reduction approach. Peer support comes from volunteers who use drugs or have personal experience with drug use. Hotline: 1-888-688-NORS(6677). More information here.
Get Involved: Research & Sharing Opportunities
How have primary healthcare leaders managed the pandemic crisis and enabled the shift to virtual care? To find out, the Alliance and our research partners are asking primary healthcare teams to answer a five-minute, six-question online survey. Your ED will soon be be receiving a formal invitation by email from the research team, and they’ll be encouraged to share it with all managers in your organization. The survey is completely anonymous, and participation is optional. For more information, contact [email protected].
What supports can help providers feel confident in providing COVID vaccine counselling? This 10-minute online survey about public beliefs and perceptions of the COVID-19 vaccines will help support provincial vaccination efforts and help providers communicate clearly about them with their clients. Respondents will be invited to re-take the survey monthly until April. Research conducted by the Alliance and partners at Women’s College Hospital. For more information, contact [email protected] or [email protected].

Care Coordination during COVID-19: It’s not too late to take part in this study by the Alliance and our research partners! They’re exploring how complex care programs in Ontario’s interprofessional primary healthcare organizations have been impacted by COVID-19, and whether embedded care coordination makes a difference. Findings will generate new best-practice recommendations. One staff member from each organization should complete this 10-minute online survey. To learn more, email [email protected].

Help All.Can Canada improve the pre-diagnosis experience of people with cancer: Provider are invited to complete this 10-minute survey (also available in French). Together with client interviews and a literature review, they will contribute to a research project that identifies areas for improvement in care along the diagnostic pathway. More information: [email protected]

Research opportunity for clients with diabetes and their caregivers: A research team at St. Michael’s hospital is looking for people over 18 living with diabetes, and their caregivers, to complete a 10-to15-minute online survey about how COVID-19 has affected their diabetes management and their overall wellbeing. Contact Carlos Escudero at [email protected].

Reimagining Governance is an opportunity to help the Ontario Nonprofit Network and Ignite NPs develop a new model for innovation in non-profit governance. Learning Labs will be offered through winter/spring 2021 for organizations who want to participate in a "deep dive" of experimentation, learning, and revision. The fully-developed model will be available to organizations in Fall 2021

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