- Email: [email protected]
A network to improve emergency patient care by facilitating practitioners to effectively support practitioners
ORIGINAL ARTICLE
A network to improve emergency patient care by facilitating practitioners to effectively support practitioners Jim Christenson, MD, FRCPC
Abstract—Networks that integrate academic and clinical activities are developing across Canada. The University of British Columbia, Department of Emergency Medicine, is leading the planning and implementation of a network that integrates clinician researchers and clinical experts with all practitioners in emergency medicine across the province. The intention is to facilitate emergency practitioners supporting emergency practitioners in remote to tertiary care settings to deliver best practices to patients in all BC emergency departments. The structure and objectives of the network demonstrate how focusing directly on patientcentred care across a large dispersed group of caregivers with common needs can effectively improve care delivery.
E
mergency Departments (EDs) address the immediate and often unexpected health needs of our citizens and manage the transition from care in the community to an acute hospital. In British Columbia (BC), more than 1000 physicians (many working part time in conjunction with family practice) manage 2,000,000 ED visits each year in 100 EDs.1 The practice of Emergency Medicine (EM) is extremely broad. Keeping up with current knowledge and skills is challenging, and best practices for many conditions are unclear. Observed variation in care suggests unnecessary morbidity, mortality, and costs. Large hospital EDs are staffed by full-time, certified, career-oriented emergency physicians, whereas small community EDs are typically staffed by general practitioners, most without additional EM certification. However, a practitioner, in any ED, can be presented with the same difficult, complex, or life-threatening patient emergency. Despite congested EDs and the reality of providing care in inappropriate places such as waiting rooms, physicians are expected to (and should) consistently provide patientcentred best practices, avoid medical errors, improve patient outcomes, and reduce costs. There is a need for a comprehensive program to facilitate the consistent delivery of best emergency clinical care. The mission of the University of British Columbia (UBC) Department of Emergency Medicine (DEM) is to train future emergency practitioners, educate medical students, and research better ways to practice EM. The vision is patient centred, aimed at improving emergency care across the From the Department of Emergency Medicine, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada. Corresponding author: Jim Christenson, MD, FRCPC, Department of Emergency Medicine, University of British Columbia Faculty of Medicine, Room 3300, 3rd Floor, 910 West 10th Ave, Vancouver, British Columbia, Canada, V5Z 1M9. (e-mail: [email protected]) Healthcare Management Forum 2014 27:132–135 0840-4704/$ - see front matter & 2014 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hcmf.2014.05.004
province: “A provincially integrated department committed to clinical and academic leadership in the creation and exchange of knowledge to promote excellence in emergency care.”
THE SEPARATION OF CLINICAL AND ACADEMIC ACTIVITIES Although EM in BC includes examples of the pursuit of excellence, there is little provincial coordination. Emergency medicine research is irrelevant if it is not “translated” and used by those who provide emergency care, but researchers are relatively isolated from many frontline emergency care providers. Despite an EM community rich with experts, the sharing of knowledge rarely extends past the local ED. We have an opportunity (perhaps an obligation) to share knowledge relevant to best practices within our community more effectively and efficiently.
INTEGRATING CLINICAL AND ACADEMIC EMERGENCY MEDICINE Some focused knowledge-sharing programs in the EM community do enjoy modest success. Evidence 2 excellence2 built an EM community of practice to share topics in clinical and administrative practice through a webinar format. The BC Patient Safety and Quality Council and the Ministry of Health Clinical Care Management Program3 supports the implementation of stroke and sepsis care guidelines. Davidson et al.4 developed recommendations to improve patient-centred care in the intensive care unit setting. One of the central components is ensuring that clinicians are supported in their clinical care options. However, a totally new approach to support the clinical community to consistently apply best emergency practices is needed. Rather than focus on a specific disease or presentation one by one, the focus should encompass the broad needs of all emergency practitioners. Incremental improvements in many key clinical areas will affect more
A NETWORK TO IMPROVE EMERGENCY PATIENT CARE BY FACILITATING PRACTITIONERS TO EFFECTIVELY SUPPORT PRACTITIONERS
patients than a few large projects aimed at small patient groups. Can we develop the capacity to effectively share the existing expertise within the EM community to broadly support better, safer patient care in a consistent, sustainable, and measurable way?
OUR APPROACH: A NETWORK OF EMERGENCY MEDICINE In mid-2012, faculty in the UBC DEM discussed the value of a network in emergency medicine as a key strategy to fulfill the DEM vision. We dreamed of a new organization with a separate but aligned vision: “Emergency practitioners supporting emergency practitioners to deliver best emergency care.” We envisioned a vibrant community network of emergency practitioners, academics and healthcare managers collaborating to solve real problems, which include the following:
Clinicians across the province engaging in defining and prioritizing care issues.
Knowledgeable researchers or quality improvement
experts working with clinicians to prioritize, investigate, and develop solutions to real clinical problems. Health policy-makers, emergency researchers, and practitioners supporting policy innovations together. Expert emergency practitioners efficiently sharing best practices and clinical support tools on a wide range of clinical issues for use by all emergency practitioners in BC. Emergency groups across the province sharing successful implementation of new care processes or policy. All emergency practitioners with easy access to core continuing professional development. Real-time clinical support available when needed.
We followed the methods and tools for Networks developed by Robeson5 and were mindful of the framework for diffusion of information as described by Rogers including sequential steps in the innovation process: knowledge, persuasion, decision, implementation, and confirmation.6 We felt supported by the broader national direction advocating for health networks. The Association of Canadian Academic Healthcare Organizations' Academic Health Science Centre (AHSC) Taskforce concluded: “AHSCs will need to evolve to Academic Health Science Networks that develop complementary education, research and patient care strengths in each component part within their region.”7 In 2010, a subsequent report defined the vision: “Academic Health Sciences Networks (AHSNs) will improve the health of Canadians and enable Canada to be a global leader in healthcare, education and research.”8 The report goes on to say, “In our view, achieving this vision requires
the full integration of research and education with patient care, so that research is connected and relevant and knowledge is translated into action to improve the health and healthcare of Canadians.” We concluded that a network would provide the broad benefits described by Popp et al., which include access and leverage of resources, shared risk, efficiency, service quality, advocacy and learning capacity, positive deviance, innovation, shared accountability, flexibility, and responsiveness.9 Popp et al. also summarized a rich literature defining when a network would be the right organizational form.10-16 A network in emergency medicine met all of the described attributes: beyond the capacity of one organization; high-influence, complex issues; failure of traditional methods; a common aim; similar cultures and values; diversity among organizations; and the requirement for a long-term interorganizational effort.
PRIMARY NETWORK GOALS We plan to support emergency practitioners in BC so that patients in all EDs in BC receive the best clinical care through the following:
A sustainable, vibrant, and active communication
network of policy-makers, emergency care leaders, researchers, quality care experts, educators, and practitioners. Increased capacity to create and synthesize relevant knowledge. Aligning researchers to define better practices. Development of real-time support to advise and support clinicians. Coordinated, comprehensive continuing professional development to optimize practitioner knowledge and skills.
PRIMARY GOALS DEVELOPED INTO FOUR FUNCTIONAL PROGRAMS Four functional programs will support EM practitioners to deliver best care. Descriptions of best practices relevant to the various emergency settings: Clinical experts will define best practices for important clinical topics. These documents will include distinct versions for remote, rural, large community, and tertiary settings. Each will be held in a central, easily updated, accessible repository. The expert will consult with practitioners before publication and then lead an ongoing electronic conversation with practitioners to continue refinement and knowledge sharing. These best practices will be based on evidence and expertise but will be easily digestible in a few minutes. Creating better practices: Clinician scientists will collate existing knowledge or investigate better ways to deliver care.
Healthcare Management Forum Forum Gestion des soins de santé – Fall/Automne 2014
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Christenson
Comprehensive, accessible, and continual professional development: Needs of practitioners will be defined and the many excellent current education programs integrated and expanded where necessary to ensure deep penetration of core education into the community. Real-time support from experts when needed: A system of real-time support for practitioners will encompass social media solutions, phone advice solutions, and video consultations to guide care in difficult cases.
ESSENTIAL PARTNERS Specific partners in the EM Network will include the UBC DEM, the UBC Department of Family Practice Rural Care Collaborative, The UBC Continuing Professional Development office and its rural committee, the UBC Faculty of Medicine, the BC Ministry of Health, the Emergency Services Advisory Committee to the Ministry, the BC Patient Safety and Quality Council, the five Regional Health Authorities, all 100 EDs in BC, all 1000 emergency practitioners in BC, EM clinician scientists, EM clinical topic experts, and independent network evaluation experts.
guidelines that we summarize on the network repository. The implementation of best practices will be supported and enhanced with effective continuing professional development and real-time support. Practitioner satisfaction will inform us of the effectiveness of network communications and engagement and whether we are successful at meeting their needs and helping them to provide best practice. We hope that increased physician satisfaction and comfort in the emergency environment will encourage more physicians to locate or continue to practice in small communities. The consequence will be fewer temporary or permanent closures of rural EDs due to physician staff shortages.
CHALLENGES We expected the following challenges:
The time and thoughtfulness to understanding
IMPLEMENTATION AND EVALUATION We intend to follow the specific constructs of the Consolidated Framework For Implementation Research described by Damschroder et al.17 within 5 major domains: evidence strength and quality; patient needs and resources; culture, leadership engagement; individual characteristics; and implementation (planning, engaging, executing, and reflecting). Evaluation will play a role from the start and provide not only data after implementation but also for ongoing reflection and the opportunity for course improvements during implementation.
THE BENEFITS WE INTEND TO REALIZE The network is closely aligned with the refreshed BC Ministry of Health 3-year strategic plan. It supports a quality and sustainable service delivery system through patient-centred care, a strengthened interface between primary and specialist care, and better linkages with interprofessional teams. The network also directly supports several key Ministry strategies: quality, skilled change management, an engaged well-led workforce, efficient use of information technology, and efficient use of resources.18 We intend to demonstrate better care and evidence of reduced cost. By clarifying best practices for 25-50 patient presentations that have either a wide variability of practice or frequent patient safety events, we are confident that we will improve care for a large number of patients. This is in distinct contrast to what can be achieved through a small number of formal clinical practice guidelines. In fact, increased emergency practitioner engagement will improve compliance with other, relevant pre-existing 134
stakeholder views and engage leaders in a conversation about network concepts. The difficulty engaging the Ministry of Health during changes in elected officials, senior managers, and strategic priorities. The time to engage busy health authority leaders. Identifying and developing communications pathways for all emergency practitioners. Establishing funding sources in a fiscally restrained environment.
CRITICAL LESSONS LEARNED SO FAR As new network leaders, we have learned a great deal. Planning for the network must be flexible with continual refinements. Stakeholders hear the plan differently and place it in their own context, often requesting that the network offer solutions to other issues not necessarily consistent with core network goals. Meeting differing stakeholder needs and defining how the network might assist each stakeholder is essential, but it slows the process. Despite support for the concept of an EM Network, some are concerned that broad clinical academic integration will not be as effective if it proceeds as a number of separate discipline-specific projects. Our argument remains that the EM Network is aligned with broader clinical academic integration and is more advanced in specific planning. We will continue to argue that its implementation as a functional prototype will contribute important active learning to inform multidisciplinary academic health sciences integration. Finally, we have learned that communicating with our primary stakeholders—1000 emergency practitioners in 100 EDs—is difficult. Continued engagement with the community of practitioners will be through the medical leadership in each of these facilities until we develop a real
Healthcare Management Forum Forum Gestion des soins de santé – Fall/Automne 2014
A NETWORK TO IMPROVE EMERGENCY PATIENT CARE BY FACILITATING PRACTITIONERS TO EFFECTIVELY SUPPORT PRACTITIONERS
presence and establish communications directly with the emergency practitioners themselves.
SUMMARY The BC EM Network is in its early stages of implementation but has a well-articulated plan and support in concept from virtually all of its stakeholders. The network is key to broadly improving patient-centred emergency care across a diverse province. Success depends on committed resources to implement the 4 functional programs that comprehensively support emergency practitioners in all types of emergency settings.
REFERENCES 1. Marsden J, Harris D. Survey of emergency department medical leaders in BC, unpublished; 2005. 2. Marsden. 〈http://ehealth.med.ubc.ca/projects/e2e/〉; 2012. 3. 〈http://bcpsqc.ca/clinical-improvement/〉. 4. Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med 2007;35(2):605–622. 5. Robeson, P. Networking in Public Health: Exploring the value of networks to the National Collaborating Centres for Public Health. Hamilton, ON: National Collaborating Centre for Methods and Tools. /http://www.nccmt.ca/pubs/Networking PaperApr09EN_WEB.pdfS; 2009. 6. Rogers EM. Diffusion of innovations. New York: The freepress, 1995; mail.im.tku.edu.tw. [EDUC, HM 101, R57, 1995]. 7. Bressler Bernie, Campbell Brad. Securing the future of Canada's academic health sciences centres: a case study describing the current state and future issues. ISBN 978-09812365-2-0; 2010.
8. Glenn Brimacombe and members of the Academic Health Science Center Task Force. Three missions, one future... optimizing the performance of Canada's academic health sciences centres. A report from the National Task Force on the Future of Canada's Academic Health Sciences Centres. ISBN 978-0-9812365-9-9; May 2010. 9. Popp J, MacKean G, Casebeer A, Milward HB, Lindstrom R. Inter-organizational networks: a critical review of the literature to inform practice; 2013. 10. Bryson JM, Crosby BC, Stone MM. The design and implementation of cross-sector collaborations: propositions from the literature. Public Adm Rev 2006;66(suppl. 1):44–55. 11. Holley J. Network Weaver Handbook: A Guide to Transformational Networks. Athens, Ontario: Network Weaver Publishing; 2012. 12. Huxham C, Vangen S. Managing to Collaborate: The Theory and Practice of Collaborative Advantage. New York: Routledge; 2005. 13. Keast R, Mandell MP, Brown K, Woolcock G. Network structures: working differently and changing expectations. Public Adm Rev 2004;64(3):363–371. 14. McGuire M. Collaborative public management: assessing what we know and how we know it. Public Adm Rev 2006;66(s1):33–43. 15. Provan KG, Lemaire RH. Core concepts and key ideas for understanding public sector organizational networks: using research to inform scholarship and practice. Public Adm Rev 2012;72(5):638–648. 16. Raab J, Milward HB. Dark networks as problems. J Public Adm Res Theory 2003;13(4):413–439. 17. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4(1):50. 18. Setting priorities for the BC health system: BC-Health-Feb14. pdf. 〈http://www.health.gov.bc.ca/library/publications/year/ 2014/Setting-priorities-〉.
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A network to improve emergency patient care by facilitating practitioners to effectively support practitioners Jim Christenson, MD, FRCPC
Abstract—Networks that integrate academic and clinical activities are developing across Canada. The University of British Columbia, Department of Emergency Medicine, is leading the planning and implementation of a network that integrates clinician researchers and clinical experts with all practitioners in emergency medicine across the province. The intention is to facilitate emergency practitioners supporting emergency practitioners in remote to tertiary care settings to deliver best practices to patients in all BC emergency departments. The structure and objectives of the network demonstrate how focusing directly on patientcentred care across a large dispersed group of caregivers with common needs can effectively improve care delivery.
E
mergency Departments (EDs) address the immediate and often unexpected health needs of our citizens and manage the transition from care in the community to an acute hospital. In British Columbia (BC), more than 1000 physicians (many working part time in conjunction with family practice) manage 2,000,000 ED visits each year in 100 EDs.1 The practice of Emergency Medicine (EM) is extremely broad. Keeping up with current knowledge and skills is challenging, and best practices for many conditions are unclear. Observed variation in care suggests unnecessary morbidity, mortality, and costs. Large hospital EDs are staffed by full-time, certified, career-oriented emergency physicians, whereas small community EDs are typically staffed by general practitioners, most without additional EM certification. However, a practitioner, in any ED, can be presented with the same difficult, complex, or life-threatening patient emergency. Despite congested EDs and the reality of providing care in inappropriate places such as waiting rooms, physicians are expected to (and should) consistently provide patientcentred best practices, avoid medical errors, improve patient outcomes, and reduce costs. There is a need for a comprehensive program to facilitate the consistent delivery of best emergency clinical care. The mission of the University of British Columbia (UBC) Department of Emergency Medicine (DEM) is to train future emergency practitioners, educate medical students, and research better ways to practice EM. The vision is patient centred, aimed at improving emergency care across the From the Department of Emergency Medicine, University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada. Corresponding author: Jim Christenson, MD, FRCPC, Department of Emergency Medicine, University of British Columbia Faculty of Medicine, Room 3300, 3rd Floor, 910 West 10th Ave, Vancouver, British Columbia, Canada, V5Z 1M9. (e-mail: [email protected]) Healthcare Management Forum 2014 27:132–135 0840-4704/$ - see front matter & 2014 Canadian College of Health Leaders. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.hcmf.2014.05.004
province: “A provincially integrated department committed to clinical and academic leadership in the creation and exchange of knowledge to promote excellence in emergency care.”
THE SEPARATION OF CLINICAL AND ACADEMIC ACTIVITIES Although EM in BC includes examples of the pursuit of excellence, there is little provincial coordination. Emergency medicine research is irrelevant if it is not “translated” and used by those who provide emergency care, but researchers are relatively isolated from many frontline emergency care providers. Despite an EM community rich with experts, the sharing of knowledge rarely extends past the local ED. We have an opportunity (perhaps an obligation) to share knowledge relevant to best practices within our community more effectively and efficiently.
INTEGRATING CLINICAL AND ACADEMIC EMERGENCY MEDICINE Some focused knowledge-sharing programs in the EM community do enjoy modest success. Evidence 2 excellence2 built an EM community of practice to share topics in clinical and administrative practice through a webinar format. The BC Patient Safety and Quality Council and the Ministry of Health Clinical Care Management Program3 supports the implementation of stroke and sepsis care guidelines. Davidson et al.4 developed recommendations to improve patient-centred care in the intensive care unit setting. One of the central components is ensuring that clinicians are supported in their clinical care options. However, a totally new approach to support the clinical community to consistently apply best emergency practices is needed. Rather than focus on a specific disease or presentation one by one, the focus should encompass the broad needs of all emergency practitioners. Incremental improvements in many key clinical areas will affect more
A NETWORK TO IMPROVE EMERGENCY PATIENT CARE BY FACILITATING PRACTITIONERS TO EFFECTIVELY SUPPORT PRACTITIONERS
patients than a few large projects aimed at small patient groups. Can we develop the capacity to effectively share the existing expertise within the EM community to broadly support better, safer patient care in a consistent, sustainable, and measurable way?
OUR APPROACH: A NETWORK OF EMERGENCY MEDICINE In mid-2012, faculty in the UBC DEM discussed the value of a network in emergency medicine as a key strategy to fulfill the DEM vision. We dreamed of a new organization with a separate but aligned vision: “Emergency practitioners supporting emergency practitioners to deliver best emergency care.” We envisioned a vibrant community network of emergency practitioners, academics and healthcare managers collaborating to solve real problems, which include the following:
Clinicians across the province engaging in defining and prioritizing care issues.
Knowledgeable researchers or quality improvement
experts working with clinicians to prioritize, investigate, and develop solutions to real clinical problems. Health policy-makers, emergency researchers, and practitioners supporting policy innovations together. Expert emergency practitioners efficiently sharing best practices and clinical support tools on a wide range of clinical issues for use by all emergency practitioners in BC. Emergency groups across the province sharing successful implementation of new care processes or policy. All emergency practitioners with easy access to core continuing professional development. Real-time clinical support available when needed.
We followed the methods and tools for Networks developed by Robeson5 and were mindful of the framework for diffusion of information as described by Rogers including sequential steps in the innovation process: knowledge, persuasion, decision, implementation, and confirmation.6 We felt supported by the broader national direction advocating for health networks. The Association of Canadian Academic Healthcare Organizations' Academic Health Science Centre (AHSC) Taskforce concluded: “AHSCs will need to evolve to Academic Health Science Networks that develop complementary education, research and patient care strengths in each component part within their region.”7 In 2010, a subsequent report defined the vision: “Academic Health Sciences Networks (AHSNs) will improve the health of Canadians and enable Canada to be a global leader in healthcare, education and research.”8 The report goes on to say, “In our view, achieving this vision requires
the full integration of research and education with patient care, so that research is connected and relevant and knowledge is translated into action to improve the health and healthcare of Canadians.” We concluded that a network would provide the broad benefits described by Popp et al., which include access and leverage of resources, shared risk, efficiency, service quality, advocacy and learning capacity, positive deviance, innovation, shared accountability, flexibility, and responsiveness.9 Popp et al. also summarized a rich literature defining when a network would be the right organizational form.10-16 A network in emergency medicine met all of the described attributes: beyond the capacity of one organization; high-influence, complex issues; failure of traditional methods; a common aim; similar cultures and values; diversity among organizations; and the requirement for a long-term interorganizational effort.
PRIMARY NETWORK GOALS We plan to support emergency practitioners in BC so that patients in all EDs in BC receive the best clinical care through the following:
A sustainable, vibrant, and active communication
network of policy-makers, emergency care leaders, researchers, quality care experts, educators, and practitioners. Increased capacity to create and synthesize relevant knowledge. Aligning researchers to define better practices. Development of real-time support to advise and support clinicians. Coordinated, comprehensive continuing professional development to optimize practitioner knowledge and skills.
PRIMARY GOALS DEVELOPED INTO FOUR FUNCTIONAL PROGRAMS Four functional programs will support EM practitioners to deliver best care. Descriptions of best practices relevant to the various emergency settings: Clinical experts will define best practices for important clinical topics. These documents will include distinct versions for remote, rural, large community, and tertiary settings. Each will be held in a central, easily updated, accessible repository. The expert will consult with practitioners before publication and then lead an ongoing electronic conversation with practitioners to continue refinement and knowledge sharing. These best practices will be based on evidence and expertise but will be easily digestible in a few minutes. Creating better practices: Clinician scientists will collate existing knowledge or investigate better ways to deliver care.
Healthcare Management Forum Forum Gestion des soins de santé – Fall/Automne 2014
133
Christenson
Comprehensive, accessible, and continual professional development: Needs of practitioners will be defined and the many excellent current education programs integrated and expanded where necessary to ensure deep penetration of core education into the community. Real-time support from experts when needed: A system of real-time support for practitioners will encompass social media solutions, phone advice solutions, and video consultations to guide care in difficult cases.
ESSENTIAL PARTNERS Specific partners in the EM Network will include the UBC DEM, the UBC Department of Family Practice Rural Care Collaborative, The UBC Continuing Professional Development office and its rural committee, the UBC Faculty of Medicine, the BC Ministry of Health, the Emergency Services Advisory Committee to the Ministry, the BC Patient Safety and Quality Council, the five Regional Health Authorities, all 100 EDs in BC, all 1000 emergency practitioners in BC, EM clinician scientists, EM clinical topic experts, and independent network evaluation experts.
guidelines that we summarize on the network repository. The implementation of best practices will be supported and enhanced with effective continuing professional development and real-time support. Practitioner satisfaction will inform us of the effectiveness of network communications and engagement and whether we are successful at meeting their needs and helping them to provide best practice. We hope that increased physician satisfaction and comfort in the emergency environment will encourage more physicians to locate or continue to practice in small communities. The consequence will be fewer temporary or permanent closures of rural EDs due to physician staff shortages.
CHALLENGES We expected the following challenges:
The time and thoughtfulness to understanding
IMPLEMENTATION AND EVALUATION We intend to follow the specific constructs of the Consolidated Framework For Implementation Research described by Damschroder et al.17 within 5 major domains: evidence strength and quality; patient needs and resources; culture, leadership engagement; individual characteristics; and implementation (planning, engaging, executing, and reflecting). Evaluation will play a role from the start and provide not only data after implementation but also for ongoing reflection and the opportunity for course improvements during implementation.
THE BENEFITS WE INTEND TO REALIZE The network is closely aligned with the refreshed BC Ministry of Health 3-year strategic plan. It supports a quality and sustainable service delivery system through patient-centred care, a strengthened interface between primary and specialist care, and better linkages with interprofessional teams. The network also directly supports several key Ministry strategies: quality, skilled change management, an engaged well-led workforce, efficient use of information technology, and efficient use of resources.18 We intend to demonstrate better care and evidence of reduced cost. By clarifying best practices for 25-50 patient presentations that have either a wide variability of practice or frequent patient safety events, we are confident that we will improve care for a large number of patients. This is in distinct contrast to what can be achieved through a small number of formal clinical practice guidelines. In fact, increased emergency practitioner engagement will improve compliance with other, relevant pre-existing 134
stakeholder views and engage leaders in a conversation about network concepts. The difficulty engaging the Ministry of Health during changes in elected officials, senior managers, and strategic priorities. The time to engage busy health authority leaders. Identifying and developing communications pathways for all emergency practitioners. Establishing funding sources in a fiscally restrained environment.
CRITICAL LESSONS LEARNED SO FAR As new network leaders, we have learned a great deal. Planning for the network must be flexible with continual refinements. Stakeholders hear the plan differently and place it in their own context, often requesting that the network offer solutions to other issues not necessarily consistent with core network goals. Meeting differing stakeholder needs and defining how the network might assist each stakeholder is essential, but it slows the process. Despite support for the concept of an EM Network, some are concerned that broad clinical academic integration will not be as effective if it proceeds as a number of separate discipline-specific projects. Our argument remains that the EM Network is aligned with broader clinical academic integration and is more advanced in specific planning. We will continue to argue that its implementation as a functional prototype will contribute important active learning to inform multidisciplinary academic health sciences integration. Finally, we have learned that communicating with our primary stakeholders—1000 emergency practitioners in 100 EDs—is difficult. Continued engagement with the community of practitioners will be through the medical leadership in each of these facilities until we develop a real
Healthcare Management Forum Forum Gestion des soins de santé – Fall/Automne 2014
A NETWORK TO IMPROVE EMERGENCY PATIENT CARE BY FACILITATING PRACTITIONERS TO EFFECTIVELY SUPPORT PRACTITIONERS
presence and establish communications directly with the emergency practitioners themselves.
SUMMARY The BC EM Network is in its early stages of implementation but has a well-articulated plan and support in concept from virtually all of its stakeholders. The network is key to broadly improving patient-centred emergency care across a diverse province. Success depends on committed resources to implement the 4 functional programs that comprehensively support emergency practitioners in all types of emergency settings.
REFERENCES 1. Marsden J, Harris D. Survey of emergency department medical leaders in BC, unpublished; 2005. 2. Marsden. 〈http://ehealth.med.ubc.ca/projects/e2e/〉; 2012. 3. 〈http://bcpsqc.ca/clinical-improvement/〉. 4. Davidson JE, Powers K, Hedayat KM, et al. Clinical practice guidelines for support of the family in the patient-centered intensive care unit: American College of Critical Care Medicine Task Force 2004-2005. Crit Care Med 2007;35(2):605–622. 5. Robeson, P. Networking in Public Health: Exploring the value of networks to the National Collaborating Centres for Public Health. Hamilton, ON: National Collaborating Centre for Methods and Tools. /http://www.nccmt.ca/pubs/Networking PaperApr09EN_WEB.pdfS; 2009. 6. Rogers EM. Diffusion of innovations. New York: The freepress, 1995; mail.im.tku.edu.tw. [EDUC, HM 101, R57, 1995]. 7. Bressler Bernie, Campbell Brad. Securing the future of Canada's academic health sciences centres: a case study describing the current state and future issues. ISBN 978-09812365-2-0; 2010.
8. Glenn Brimacombe and members of the Academic Health Science Center Task Force. Three missions, one future... optimizing the performance of Canada's academic health sciences centres. A report from the National Task Force on the Future of Canada's Academic Health Sciences Centres. ISBN 978-0-9812365-9-9; May 2010. 9. Popp J, MacKean G, Casebeer A, Milward HB, Lindstrom R. Inter-organizational networks: a critical review of the literature to inform practice; 2013. 10. Bryson JM, Crosby BC, Stone MM. The design and implementation of cross-sector collaborations: propositions from the literature. Public Adm Rev 2006;66(suppl. 1):44–55. 11. Holley J. Network Weaver Handbook: A Guide to Transformational Networks. Athens, Ontario: Network Weaver Publishing; 2012. 12. Huxham C, Vangen S. Managing to Collaborate: The Theory and Practice of Collaborative Advantage. New York: Routledge; 2005. 13. Keast R, Mandell MP, Brown K, Woolcock G. Network structures: working differently and changing expectations. Public Adm Rev 2004;64(3):363–371. 14. McGuire M. Collaborative public management: assessing what we know and how we know it. Public Adm Rev 2006;66(s1):33–43. 15. Provan KG, Lemaire RH. Core concepts and key ideas for understanding public sector organizational networks: using research to inform scholarship and practice. Public Adm Rev 2012;72(5):638–648. 16. Raab J, Milward HB. Dark networks as problems. J Public Adm Res Theory 2003;13(4):413–439. 17. Damschroder LJ, Aron DC, Keith RE, Kirsh SR, Alexander JA, Lowery JC. Fostering implementation of health services research findings into practice: a consolidated framework for advancing implementation science. Implement Sci 2009; 4(1):50. 18. Setting priorities for the BC health system: BC-Health-Feb14. pdf. 〈http://www.health.gov.bc.ca/library/publications/year/ 2014/Setting-priorities-〉.
Healthcare Management Forum Forum Gestion des soins de santé – Fall/Automne 2014
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