Last revised: April 23, 2021

Right Care Alberta

PLAYBOOK

Implementing Choosing Wisely CanadaTM

Recommendations

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Table of Contents

TOPIC PAGE

Right Care Alberta ........................................................ 3

Choosing Wisely Canada .............................................. 3

What is Choosing Wisely? ............................................ 4

Why this Matters? ......................................................... 4

Benefits of Choosing Wisely ........................................ 5

Getting Started ............................................................. 5

Site Leadership Driven Approach ................................ 6

Develop an Implementation Plan .................................. 8

The Sprint Approach .................................................... 11

How to Decide Which Approach to Choose? .............. 13

Choosing Wisely Canada Hospital Designation .......... 14

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Right Care Alberta

Giving Albertans the best possible health outcomes will always be the focus of

Alberta Health Services. That’s why we are changing the conversation between

patients and providers to improve care and how that care is delivered.

We will do this through Right Care Alberta and with our front-line teams. Right Care

Alberta focuses on individual patient needs, ensuring patients only have tests,

treatments and clinical procedures that will improve their health outcomes.

This work will also reduce variations in how we care for our patients and contribute to

greater equity and efficiency wherever we deliver clinical care.

Right Care Alberta will help our healthcare workers excel. They, along with patients

and families, will share in decision-making about smarter practices and sleeker

processes aligned to patients’ personal values.

The Right Care Alberta team is dedicated to understanding front-line workers and

their patients. Our approach is to listen and learn, change and improve, together.

To talk with us or to recommend a project, send us an email at ihot@ahs.ca.

Choosing Wisely Canada, a National Initiative

This playbook is a guide, intended to provide basic information and tools to help you

start your journey of implementing Choosing Wisely Canada recommendations. The

playbook provides two distinct approaches. You can decide which approach you think

would be most suitable to your site and tailor your campaign accordingly.

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What is Choosing Wisely Canada?

Choosing Wisely Canada is the national

voice for reducing unnecessary tests and

treatments in healthcare. It launched in

2014 in partnership with the Canadian

Medical Association. Choosing Wisely

Canada has partnered with over 70

professional societies from different clinical

disciplines to develop lists of “Things

Clinicians and Patients Should Question”. These lists contain recommendations

of tests, treatments and procedures that could be reduced or stopped because

they are not supported by evidence and could impact patient care.

To date, over 300 recommendations have been published.

https://choosingwiselycanada.org/

Why This Matters

Unnecessary tests and treatments are a pervasive problem in healthcare, and

are present in virtually every hospital, department and clinic, irrespective of size

or how diligent the clinicians are who work there. A 2017 report from the

Canadian Institute of Health Information (CIHI) and Choosing Wisely Canada

showed that in many clinical areas up to 30% of tests and treatments are

potentially unnecessary. This overuse can expose patients to avoidable harms,

lengthen wait times and consume precious hospital resources.

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Benefits of Choosing Wisely

In addition to raising Alberta’s national profile through attaining the Choosing

Wisely Canada Hospital designation, your site may also achieve:

A measurable reduction in laboratory testing and associated costs;

A measurable reduction in unnecessary Diagnostic Imaging (DI) procedures

resulting in a reduction in costs and/or reduction in wait times;

Appropriate drug use (such as optimized antibiotic therapy) contributing to better

patient outcomes with fewer adverse effects, reduced antibiotic resistance rates,

and optimized resource utilization; and

Appropriate procedures or service models.

Making Choosing Wisely a part of the site-wide culture will ultimately lead to

improved quality and health outcomes and a better patient experience, while

reducing resource overuse or misuse at your site.

Getting Started

You have decided to start the journey to reduce inappropriate use of tests and treatments at your site. Because local context, culture, resources and capabilities vary widely from one site to another, there is no single recipe book for you to follow.

The Improving Health Outcomes Together (IHOT) team has prepared this playbook to introduce two implementation approaches for consideration, depending on the characteristics of your site:

1. Site Leadership Driven Approach: This approach works well if the site has a functioning quality council and an

identified leader who has the time and energy to drive this forward.

2. Sprint Approach: This approach is a creative design and problem solving technique. It helps the

teams to get the clarity they need for the problem and co-create the solutions.

In the following pages, we will discuss each approach in detail, using the five (5)

Level 1 Choosing Wisely Canada recommendations:

1. Do not order PT/INR & aPTT tests as a bundle;

2. Do not use CK testing to diagnose heart attack if troponin is available;

3. Remove “daily lab” options from order sets;

4. Do not routinely test serum and RBC Folate levels; and

5. Do not order routine chest X-rays for all ICU patients.

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Site Leadership Driven Approach

“How do I know if my site is ready for Choosing Wisely Canada recommendations”?

1. Assess for Readiness

Timing can be very important for successful implementation. Here are a few

considerations for getting ready for the journey:

It is important to time the planning and roll-out of the implementation initiative so it

does not conflict with other significant changes underway (e.g., significant staff

changes, another program being rolled out);

Consider who else should be consulted for support in moving forward. Having clinical

support services such as DI, Pharmacy and Lab on-board can help to advance the

initiative and achieve success;

Ensure there is a designated lead for the initiative and confirm that time can be

committed to this project; and

Identify all staff who are directly involved in clinical decision-making and orient them

to this opportunity (e.g., clinicians, registered nurses, interns, residents, nurse

practitioners).

a) Ask, “What do we need to change and are we ready to make those

changes?”

During this initial phase, look at the current practices at your site and ask questions

that will enable leaders to determine whether they are ready to move forward with

implementing the Choosing Wisely Canada recommendations.

Successful implementation begins and

ends with a well laid-out process.

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b) Practice Change Questionnaire

The following questionnaire describes the activities recommended as practice

changes for the five suggested Level 1 Choosing Wisely Canada recommendations

(if not relevant to your site, see Choosing Wisely for potential alternative CWC

recommendations). Use this questionnaire to review which of the practices your site

is already doing, what may need to be discontinued and which ones will need to be

changed at your site.

Note: These five recommendations have been built into Connect Care.

Begin by: Understanding how your site orders blood work (paper or

electronic)

Reviewing lab requisitions

Appraising order sets

Asking . . . If Yes . . . If No . . .

1. Does my ED order both PT/INR & aPTT as a bundle?

Recognize who needs to do what differently

Collect some baseline data and the cost associated with doing the tests (or contact the IHOT team)

Follow the Implementation plan (described below)

Your site meets the

requirement

Move to the next

recommendation

2. Does my site use CK testing to diagnose heart attack if troponin is available?

3. Are inpatients at my hospital having daily labs ordered?

4. Does my site still test serum and RBC Folate levels?

5. Does my site order routine chest X-rays for all ICU patients?

NOTE

If your hospital has launched

Connect Care, please email the

IHOT team at ihot@ahs.ca for

support in applying now for your

Level 1 Choosing Wisely Canada

Hospital designation.

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2. Develop an Implementation Plan

a) Get the implementation team together

Once you recognize that there are some practices that your site needs to change,

start by creating an implementation team. This team is responsible for moving the

Choosing Wisely Canada recommendations forward and developing a plan to

ensure the program is successful. When choosing and setting up the implementation

team, consider the following:

Look for action people—individuals who enthusiastically participate in

challenges and opportunities;

Try to ensure representation from Lab and DI and as many other key groups

as possible. This could include registered nurses, residents, interns, lead

physicians, nurse practitioners, pharmacists, and process improvement

consultants;

Implementation team membership and size will vary depending on facility size

and resources;

Outline the roles and responsibilities of the implementation team (e.g., the

team will collect baseline data, the team will understand the existing

practices);

Use your multidisciplinary implementation team to craft the interventions

specific to your site involving a combination of interventions, such as

education, order set changes, and communication.

b) Education

Education should aim to increase awareness and understanding of Choosing Wisely

Canada initiatives and campaigns. The education should be targeted to clinicians

including nurses, nurse practitioners, physicians and other clinical support services,

such as Lab, Pharmacy and DI. Awareness and education must commence before

other strategies are pursued. This ensures clinicians appreciate why changes are

being made and have a chance to provide feedback before changes go live. Advice for

developing your educational tools:

Tailor your educational initiatives to the particular area where change is

happening;

Work with all the clinicians involved in ordering the selected tests and

treatments on the target unit. Get their feedback on the kind of educational

interventions which are more likely to be successful on their unit. Some units

use posters, presentations or email blasts; and

Involve frontline providers.

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.

c) Redesign order sets & lab requisitions:

Key points to consider when revising order sets and lab requisitions include:

How does your site order blood work? Paper requisition or electronic order entry?

Both systems present opportunities and challenges;

Do you think order set design is leading to over-testing? For instance, is “daily labs”

an option on your order sets? If yes, consider changing order sets to ensure that all lab

orders have a reasonable terminus;

Provide education and guidance in order sets where possible. Include algorithms to

support decision-making based on clinical indications;

When reviewing order sets consider if tests should be bundled together or

separated. Tests are often bundled for convenience but there are different clinical

indications for when each is necessary. Make sure you are separating tests where

appropriate;

Circulate the revised order set and lab requisitions to key stakeholders and modify

based on the feedback;

Use multiple avenues to communicate the changes to staff, such as emails, posters,

or verbal updates in department meetings or during weekly huddles; and

Use process improvement tools to gain more understanding around current process

and future design. The IHOT team can support you if you need process

improvement tools.

d) Measure your performance

Key points to consider:

Are you able to collect physician or unit-level data on ordering practices? If

yes, do you notice different patterns of testing or treatments among physicians or units with similar patient populations?

A run chart can help inform how the change strategy is working;

Connect with the working group to get their feedback on initial changes;

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What has worked well? What hasn’t worked well?

How have the changes impacted their day-to-day work?

Are the changes feasible?

What would they suggest for improvement?

e) Make modifications as you learn

Constant monitoring of your statistics over the course of your project will guide

iterative changes. By monitoring the effect of your improvement, you can determine

how to fine-tune your plan to further improve during the next phase. It is also vital to

combine the data you have collected with the feedback you have received regarding

your changes. Sharing data with the services performing the program will encourage

discussion of what is working well so far and where improvements could be made. This

is also an opportunity to celebrate the success of the change strategy and

acknowledge the efforts that have contributed to the improvement.

Presenting data to larger audiences can bring more attention and support for your

initiative – all of which contributes to sustainability. By presenting at site quality

councils, grand rounds, or division meetings, you have the opportunity to highlight

what you have done so far and engage potential new partners moving forward.

3. Sustaining your success

Ensure any tools introduced during implementation are easily accessible and built-in to day-to-day processes;

Be sure to realign any tools with current evidence and guidelines over time to help promote best practices and continued use. Set regular intervals for ongoing review to keep tools up to date; and

Consider incorporating education into new hire orientation and annual competency processes.

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The Sprint Approach

https://www.d4ahs.com/

1. What is a Sprint Approach?

A Sprint Approach is a creative design and problem-solving technique that aims to

identify new solutions to existing challenges. There are no presentations or formal

input in a workshop; rather, there will be a guided process to enable teams to have

the best possible conversation with people who share similar interests and a

curiosity to solve a problem.

The Sprint Approach provides a creative opportunity for participants to:

1. Discuss topics that they are passionate about;

2. Share their learning and to learn from others;

3. Generate some new improvement ideas and visual representations; and

4. Prototype a design that they can take back to their own program to improve

health and safety.

2. Expected outcomes after a Sprint session:

Team will have deep understanding of the problem;

Team will be able to create a live campaign and get real-time feedback;

Team will have a deeper insight of what is working or not working;

Team will have a co-created solution which supports buy-in and sustainability;

and

Team will develop key messages, strategies, implementation ideas, and the

momentum to go LIVE.

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How to Decide Which Approach to Choose

The Site Leadership Driven Approach would work well if YOU HAVE . . .

. . . A functioning multidisciplinary Quality Council within your site;

. . . Knowledge of the problems and the solutions; and

. . . A dedicated team who is ready to take this initiative forward.

The Sprint Approach would be best if YOU DON’T HAVE . . .

. . . A full understanding of the problem;

. . . The team to move this forward; and

. . . Sufficient buy-in from stakeholders.

A Final Note

The five (5) recommendations used as examples are part of the Choosing Wisely

Canada Diving into Overuse in Hospitals campaign, Level 1 (see table below). Sites

interested in taking the SPRINT Approach for the Diving into Overuse in Hospitals

campaign should connect with the IHOT team for the appropriate resources.

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Choosing Wisely Canada Hospital Designation

SCOPE OF CHANGE ACTIONS*

LEVEL 1 Implement the five “quick wins”

1. Uncouple PT/INR and aPTT tests and revise ED order panels

2. Eliminate CK testing if troponin is available

3. Remove “daily lab” options from order sets

4. Remove folate testing from your

hospital’s ordering systems

5. Stop ordering routine chest X-rays in

the ICU, except to answer specific

clinical questions

LEVEL 2 Implement an additional three Choosing Wisely Canada recommendations through quality improvement methods

• Quality improvement methods must

include collection of baseline data,

the intervention(s), and collection of

results data.

• Projects could include

implementation of Choosing Wisely

Canada toolkits.

LEVEL 3 Take organization-wide

leadership on overuse and

promote culture change

• Make Choosing Wisely part of the

hospital’s operating/strategic plan.

• Implement at least 10 distinct

Choosing Wisely Canada

recommendations, across multiple

hospital departments. The

recommendations implemented in

Levels 1 and 2 may count towards

the 10.

• Mentor or collaborate with at least

one other hospital on Choosing

Wisely.

*Note: if any of these actions are

not relevant to your hospital,

please substitute from these

potential alternative CWC

recommendations.