Earlier this month, Ontario’s Niagara Health became one of the first hospitals in Canada to be recognized as a Choosing Wisely Canada Hospital in the Leadership Status level— the highest achievement awarded under the national program. The only other hospital that’s received this designation is William Osler Health System, also in Ontario. To achieve Leadership status, Niagara Health successfully participated in Using Blood Wisely, implemented a number of quality improvement initiatives to reduce overuse, made Choosing Wisely an organizational priority, and mentored a nearby hospital. Choosing Wisely Canada recently caught up with Dr. Mohammad Refaei, who spearheaded Niagara Health’s efforts.

Choosing Wisely Canada: Tell us a bit about how your hospital got involved in Choosing Wisely or more specifically, reducing overuse/low-value care?

Dr. Mohammad Refaei: Efforts to achieve Choosing Wisely accreditations were already underway by the time I joined Niagara Health in 2020. We had already achieved Choosing Wisely Canada recognition with successful and sustainable projects such as reducing post-operative use of opioids in elective surgeries and proton pump inhibitor de-prescribing practice.  There is a great sense of pride among frontline workers at Niagara Health in participating in quality improvement projects, and to reduce unnecessary testing, interventions and treatment for our patients. This engagement is coupled with a deep-rooted interest in quality from executive leadership at Niagara Health and ensuring optimal care for our patients.

I am the physician-lead and chair of the Clinical Utilization Committee, and we decided as a committee to restructure its membership to include quality improvement (QI) champions from different departments to act as liaisons and subject matter experts for QI activity in their respective areas. Their efforts are coupled with those of the clinical directors of each department, and include engagement of physicians, nurses and other frontline workers. We have set a yearly workplan for each department to review utilization indicators, identify gaps in quality, generate ideas, and devise and implement QI projects across Niagara Health’s five hospital sites.

CWC: What motivated your hospital to pursue the Choosing Wisely Canada Hospital Leadership Status?

MR: The joy of seeing no waste is at the heart of Niagara Health’s efforts to attain the Leadership Status. I worked with highly motivated colleagues, from stakeholder physicians and transfusion medicine technologists to our leadership executives, who shared a great joy in making the process more efficient, safer and optimal for the patients and staff alike.

As a hematologist, I have been interested in QI projects particularly related to reducing inappropriate transfusion of blood products. The human blood is made of a number of components that carry different functions. Federal laws mandate stringent and meticulous processing, handling and storing of blood products in order to maintain optimal quality for administration to qualified patients. Inappropriate transfusions are not only costly to the health care system, a waste of a high-demand resource, but they also unnecessarily expose patients to serious transfusion reactions.

There was a gap in the utilization of major blood products, including red cell, across Niagara Health sites. Building on previous success, and in collaboration with the Transfusion Medicine Committee and stakeholders, I implemented a multi-faceted quality improvement project to reduce inappropriate red cell transfusion across all of our sites. These interventions included educational components, changes to transfusion order set and prospective auditing of red cell orders by transfusion medicine technologists. As a result, we were able to achieve Using Blood Wisely at all of our three major sites, St. Catharines, Niagara Falls and Welland. It was a natural progression to meet the requirements for the Leadership Status of Choosing Wisely Canada. 

CWC: What was it like to mentor another hospital? What learnings from that experience will you take forward?

MR: I had the privilege of working with my counterpart at Haldimand Memorial War Hospital, a neighbouring small community site. Our mentorship started during a difficult and flux state of the COVID-19 pandemic. Despite that, we were able to meet regularly, share our methods and successes, as well as help our colleagues navigate the different aspects of quality improvement. I learned a great deal about how different hospitals are run, even within geographic proximity, particularly when it comes to medical recordkeeping.  Applying similar search queries and algorithms to collect data proved challenging. I came to further appreciate the challenges of providing clinical care in smaller hospitals. I admire my colleagues’ dedication to quality improvement projects, and the fact they shared similar interests to myself and our organization. I greatly enjoyed mentoring, and will carry it forward to other opportunities. 

CWC: What does the Leadership Status represent to your hospital?

MR: At Niagara Health, we hold ourselves accountable for high-performing, high-quality, sustainable and innovative healthcare across our hospital sites. The Clinical Utilization Committee reports to the Medical Advisory Committee, and Quality Committee of the Board. In doing so, Niagara Health demonstrates a commitment to implementing multidisciplinary, financially feasible, patient-centred quality improvement projects with the recommendations of Choosing Wisely Canada at the heart of this endeavour.

Niagara Health is committed to embedding quality improvement within the culture of our organization. Our efforts and successes noted above are a testament to the quality of work that has been done to date, and will continue.  The Leadership status provides a great deal of pride and confidence in our ability to continue quality improvement across all of our sites, and move forward with ongoing commitment to Choosing Wisely Canada.

CWC: In the future, how do you plan to continue Choosing Wisely efforts?

MR: The Clinical Utilization Committee will continue to review department-specific indicators of quality annually to ensure continuous quality improvement and sustainability of Choosing Wisely efforts. Plans to create funding competitions, quality improvement workshops, standardized submission of QI projects, and participation in Niagara Health Research Day to showcase our successes are some of the organization’s plans to support quality improvement. Current projects include reducing inappropriate echocardiograms in patients with normotensive pulmonary embolism; reducing inappropriate urine cultures and antibiotics for asymptomatic bacteriuria, another to reduce inappropriate plasma transfusion (under the Transfusion Medicine Committee). We continue to collaborate with colleagues from Brock University to engage students in the Interprofessional Education for Quality Improvement Program (I-EQUIP) to improve patient care and the patient experience. We have patient partners who are keen to participate in our ongoing quality improvement projects. We await the launch of a new hospital health information system that will be leveraged to improve our efforts to monitor utilization indicators and identify areas for ongoing improvement.