Centre de santé et de services sociaux Jeanne-Mance & Centre hospitalier de l'Université de Montréal (QC)

  • Michèle de Guise, Directrice de la promotion de la santé et conseillère à la DSP pour la gestion des épisodes de soins, Centre hospitalier de l'Université de Montréal, Montréal, Québec (Director, Health Promotion and Advisor, Care Episode Management, Public Health Department)
  • Guylaine Leblanc, Direction du bureau de projets, Centre de santé et de services sociaux Jeanne-Mance, Montréal, Québec (Project Office Directorate)
  • Roger Roberge, Directeur des affaires médicales, Centre de santé et de services sociaux Jeanne-Mance, Montréal, Québec (Director of Medical Affairs)

Implantation d’un accueil clinique 

Implementing a Clinical Intake Process

Emergency department overcrowding is problematic not only in Quebec, but throughout the industrialized world. Several authors have investigated the issue from a number of perspectives. There is no question that this situation is multifaceted and complex. It should therefore be solved by a multipronged strategic approach. Some of the reasons why our emergency departments are overcrowded include timely access to technical support and to the advice of medical specialists. This access challenge encourages family physicians to use emergency departments as a gateway to the system for conditions requiring prompt attention, although not urgent (i.e. semi-urgent conditions).

Our intervention project aims to implement a clinical intake model which will interface with community physicians, the CHUM and the CSSS Jeanne-Mance. This model is intended to be an initial step toward greater flexibility and responsiveness within our systems, in order to meet the needs of our patients. Drawing on similar initiatives implemented across Quebec, the main thrust of this intervention project is to target activities upstream of the emergency department by finding an alternative ambulatory solution to semi-urgent conditions (5 in total) that do not require emergency department involvement or hospitalization. Grouped in clinical signs or diagnostics, and according to the specific criteria established by the medical team, this ambulatory clientele will have special access to technical support and diagnostic services, visits with medical specialists and, in some cases, to the early initiation of treatment, along with patient education, based on established protocols. This is a positive step toward strengthening the front line. It is a way of reversing the trend of recent years whereby healthcare was extremely focussed on hospital services and rather providing the front line with the tools it needs to provide comprehensive care across the continuum in a more efficient manner.

First, it appeared important to clarify the needs of community physicians. A questionnaire was circulated to them that enabled us to identify the most common clinical conditions whereby they had no other choice than to steer their patients to the emergency department due to lack of timely access to technical support or lack of assistance prearranged by the CSSS. The same survey was sent to the CHUM’s emergency department physicians from the standpoint of those who admit these patients and provide a diagnosis. A subsequent validation with clinical intake managers who already practice in Quebec confirmed that these diagnoses were among the most common reasons for referring patients. The consultation process with managers who had led initiatives of this kind confirmed that it was sensible to begin with a only a few diagnoses to eventually extend the number of conditions at intake, where appropriate, as the project evolves.

Pathologies identified for the new intake process:

  1. Suspected deep thrombophlebitis
  2. Suspected transient ischemic attack
  3. Chest Pain with suspected coronary pathology
  4. Iron deficiency anemia with suspected blood loss
  5. Cellulitis unresponsive to antibiotics initiated per orem (P.O.)

With this first step completed, which from a change management perspective, already helped secure buy-in by adapting the service to identified needs, we subsequently carefully identified the key stakeholders who could influence, both positively and negatively, the implementation stage. We met with these stakeholders regularly. Our interview questions were based on Kotter’s principles: creating a sense of urgency with regard to the issue and collective acknowledgement that the status quo is unacceptable. The tremendous efforts put into alleviating emergency department overcrowding over during the past few years to little or no avail warrant tackling the problem from a different angle, by joining the strengths of the front line and hospital services throughout the entire continuum of care. 

Media and government pressure regarding chronic bottlenecks in emergency departments proved to be a strong enabler to engage the organization. Ministerial directions supporting initiatives that aim to bolster the front line in order to enable it to enhance its performance also turned out to be facilitators that enabled us to move this joint initiative forward quickly, both at the CHUM and the CSSS Jeanne-Mance levels. Moreover, in order to increase buy-in among the various stakeholders involved in the proposed change, we drew on the Cohen change model, which focuses on the importance of acting not only on individual behaviours, but also on structural drivers, such as physical infrastructures, the availability of various resources, and so forth. The fact that the clinical intake process was going to be implemented within the confines of the existing structure (the outpatient unit), with no additional resources and sufficient operating hours, brought more credibility to potential short-term gains.

With the backing of the most influential stakeholders secure, we began the implementation work. We were able to identify the “physician champions” who took on the responsibility of developing investigative and treatment algorithms based on best practices in addition to informing their colleagues of the new approach that would soon be in place. We also made sure the proposed algorithms and referral criteria could be validated by family practitioners. Alongside the creation of intake algorithms and standard order sets, a detailed mapping of the end-to-end patient journey was developed, ensuring appropriate pathways were part of all the critical touch points of the patient’s journey. Considerable attention was paid to the identification of communication channels, both at the time of referral and upon the patient’s return to the community, which are key success factors.

One of the challenges of this project was ensuring its sustainability given that the members of the project team will not be in charge of its completion in the medium term since three to four of them have refocused their careers. Given our concern for this issue, we attached significant importance to the clarification of governance and follow-up mechanisms within the existing committee structure of each of our organizations and shared between them. The roles and responsibilities of the main stakeholders and the accountability mechanisms have also been clearly spelled out.

A communication plan will be carefully drafted in advance of the project’s official launch with a view to inform the various stakeholders along the care continuum of the added value of this new care model, as well as everyone’s expected input. Community physicians will receive all the necessary information to facilitate referrals and compliance with referral criteria for patient intake. It will also be important to take this approach at the CHUM level so that staff involved in the project can work together as efficiently as possible to coordinate patient care and services. Training for nurses and other staff involved in this new care structure will be provided for both outpatient staff at CHUM and at the CSSS, with a view to help them be successful in their new role and help them gain a better understanding of the tools required to monitor patients.

Several dimensions of quality and performance are addressed in this project including: the anticipated effect on the quality and safety of care, accessibility, a demonstrable direct impact on enhanced performance, an anticipated improvement of the patient experience which remains a key issue and is the cornerstone of this new care structure. The alignment of strategic planning activities across both organizations is also an enabler, which should contribute to the project’s success. 

This project is also a single step in a colossal collaboration effort between two separate organizations, which both have ambitions in the near future to create new hospital infrastructures in a shared territory with joint responsibility for the population. One organization is hoping for a new urban hospital model, while the other aspires to be part of a large teaching hospital, which would be the fulfilment of a merger initiated more than 15 years ago. Close collaboration between these two organizations will be critical to the quality of services offered to the population.