The North Bay Regional Health Centre (NBRHC) is a large community hospital and one of four major acute care hospitals serving Northeastern Ontario. It is also the district referral centre, providing specialist services for smaller communities in the area.

In 2010, the hospital was rebuilt to include three different sites in North Bay. The new facility was a fresh start and staff saw it as an opportunity to re-examine and improve upon standard practices.

NBRHC set out to establish itself as a centre for innovation and quality improvement. “Do the right test, at the right time, for the right patient’ was described as a shared vision of clinicians and administrators” says Melissa Parker. Parker was the clinical nurse educator in the Pre- Admission Clinic at NBRHC. The clinic evaluates over 5000 patients receiving surgery at NBRHC annually, the majority of whom are undergoing low to moderate risk surgeries.

Senior leadership identified three priority areas for improving quality and efficiency when NBRHC opened in 2010, one of which was the operating rooms (OR). Parker, however, had a bigger vision beyond just the OR. “I was the educator for all of the peri-operative services. Not just OR but the pre-admission clinic, day surgery, and the post-anesthetic care unit. I had that whole process under my umbrella looking at what we were doing during each phase of surgery” said Parker. With the strong support of the hospital’s medical director, the perioperative services manager Chantal Gagne, the chief of anesthesiology, and an internist champion, Parker set out to improve the preoperative testing process at NBRHC.

But where to start? Parker looked to the literature and asked colleagues about standards of care for pre-operative screening, testing, and education in preparing patients for surgery. This is when Parker was first introduced to Choosing Wisely Canada.. “It was brought to my attention that there was this new initiative asking clinicians and patients to be more critical of standard tests and treatments”.

Parker and the multidisciplinary team started evaluating current screening processes for patients. They assessed surgical risk standards and guidelines used for preoperative testing at NBRHC. It was through this that new processes were established that involved the development of medical directives for screening and preoperative testing.

As with any process change, there was initial hesitancy and a feeling that this was outside of the nursing scope of practice, or in the case of laboratory services ‘disrupting the norm’. In addition, clinicians raised concerns that the new process could negatively affect patient care. Parker recalls, “we put a lot of effort into educating both nurses and physicians around patient specific processes and implementation of medical directives, ensuring them this was in scope for nursing practice, and that by following the new processes as per Choosing Wisely, we were actually reducing the chances for surgery delay, false positives, and patient anxiety.” The multidisciplinary team introduced the changes step by step, gradually bringing nursing staff onboard. Reviewing the new process in a learning environment without patients, then small trials with feedback, working through the intricacies with laboratory services and eventually scaling to all surgery.

Over two years, Parker saw a significant change in how key players and stakeholders were adapting to the process. . ‘If you were to ask a nurse now in comparison to when we first proposed this change I think you would hear there’s a sense of empowerment and a lot of critical thinking involved. Now our nursing staff have a deep understanding of evidence- based best practices when it comes to preoperative surgery and achieving the best patient outcomes” she says.

The pre-surgical process Parker and the team put in place is now standard practice at NBRHC. In 2017, Parker left her role at NBHRC to pursue a teaching position in the Collaborative BScN program at Nipissing University and Canadore College. She still takes shifts at the hospital and shares ‘I use the process when I work in the preadmission clinic and it’s a reminder of all the hard work and time we put into this project.’

The grassroots nature of the approach at NBRHC is reflective of the principles of the Choosing Wisely Canada campaign: clinician-led, patient-centred, multi-professional, evidence-based, and transparent.