Innovative Infrastructure for a Department of Pediatric Surgery

Innovative Infrastructure for a Department of Pediatric Surgery

Surgery on children and youth account for a small percentage of the total number of surgeries performed in B.C. each year, yet present some of the greatest challenges and triumphs.

The healthcare system in British Columbia is undergoing significant change, as it has for quite some time. This environment of change provides opportunity to establish a new vision for Pediatric Surgical Services in B.C.

The Department of Pediatric Surgery at B.C. Children’s Hospital published its new vision, For Care, For Quality, For Life in 2003. It established a framework for strategic planning to improve the health of children in B.C. who require pediatric surgical services.

Integral to this vision was the creation of an Office of Pediatric Surgical Evaluation and Innovation (OPSEI). OPSEI served to provide scientific insight to support policy makers, managers, planners, clinicians and researchers in shaping the future of Pediatric Surgery in British Columbia and internationally. It focused its strategy in three areas: Evaluative Research, Education and Development, and Policy Creation. A business plan and strategic framework were developed and supported by the hospital executive and an Executive Director, Managing Director, Operations Research Analyst and Program Assistant were recruited. To support the achievement of the three primary outcomes, competitive grants and donations were obtained.

Six inter-related elements in For Care, For Quality, For Life created the foundation for continuous quality and improvement, ensuring access to the best care in the best setting for the best outcomes. The new vision was comprised of six inter related: 1. the “Patient and Family”; 2. a Network for Pediatric Surgical Services (within the framework of the Provincial Health Authority); 3. a service delivery model based on community, regional and provincial services; 4. a Network for Pediatric Surgical Services; 5. Clinical Imperatives, including surgical oncology and re-constructive surgery; and 6. Education and Evaluation. The initiative was supported by an Office for Pediatric Surgical Evaluation and Innovation. The Office of Pediatric Surgical Evaluation and Innovation (OPSEI) became a key element to achieving the new vision.

Background

Pediatric surgery at BCCH is comprised of the Divisions of General Surgery, Cardiovascular and Thoracic Surgery, Otolaryngology, Urology, Plastic Surgery, Neurosurgery, Dentistry and the Departments of Orthopedic Surgery and Ophthalmology. The Department of Pediatric Surgery has the mandate for education and research, per the vision and mission of Children and Women’s Health Centre of British Columbia, and as part of the Provincial Health Services Authority promotes the delivery of accessible quality health services for children and youth through an integrated health system. Pediatric surgical services in BC are provided in all health authorities, with the majority of specialized and unique services provided at BCCH. Historically, planning for pediatric surgical services throughout BC has not been done through a collaborative, integrated and coordinated process but in response to internal and external pressures within each hospital and health authority. These pressures have resulted in the diminishing capacity of many facilities to provide pediatric surgical services.

Specific pressures have so impacted the workload of surgeons that the clinical, academic and research mandates of the Department of Pediatric Surgery at BCCH were significantly challenged. In short, as providing tertiary care involves constant change, a tertiary facility must be able to support and respond to rapidly changing internal and external pressures.

Responding to change has consistently presented a challenge. In part, resistance has resulted from the additional expenditures associated with advances in tertiary care. Funding models have not readily supported innovation, while budget processes have often been slow to respond, due to the legal implications of new treatments that have poorly established outcomes and little evidence of efficacy.

With significant financial and human resource constraints at the time of the establishment of OPSEI, it was essential that surgeons knew that what they were doing was both having a meaningful impact and was cost effective. Accordingly, evaluation of the impact of surgical techniques and new innovation on the lives of children and youth was of particular importance. It was felt that the lack of a coordinated, comprehensive system to support outcomes evaluation and new technology assessment for pediatric surgery was hindering the introduction and adoption of new techniques.

The Vision

The Patient and Family Network

Family-Centred care was the central theme in the For Care, For Quality, For Life vision.  As essential members of the healthcare team, families played a vital role in the healing process.  BCCH remains committed to working with patients and families and to draw from their strength, knowledge and experience of the process of care giving and decision making.

Network for Pediatric Surgical Services

Formation of the Network for Pediatric Surgical Services within the framework of the Provincial Child Health Network in British Columbia provided a mechanism for achieving improved pediatric surgical outcomes. There was a clear need for greater collaboration, coordination and planning of pediatric surgical services in B.C.

Service Delivery

Challenges, such as establishing meaningful indicators of primary, secondary and tertiary care, achieving timely access to care, developing common standards and guidelines for the delivery of safe, efficacious care and evaluation and monitoring throughout BC were priority issues to be addressed. This delivery was supported by the development of common standards and protocols, case classifications and quality performance and improvement initiatives that were evaluated and feedback was provided into the decision making and prioritization process. The intent of the Service Delivery Model was to provide for all levels of pediatric surgical services in the best settings. The model consisted of community, regional and provincial services that provided increasing levels of specialized and unique pediatric surgical care to children and youth throughout B.C. Provincial Services offered the highest level of specialized care and were centralized at BCCH. Restructuring of surgical services at BCCH was required so that high volume/low intensity cases did not conflict with low volume/high intensity cases that required specialized and unique care. To achieve this balance, a Pediatric Day Surgery Centre was proposed.

Clinical Imperatives

Two clinical imperatives were developed to support strategic planning of the Department of Pediatric Surgery. They were defined as areas of distinction currently present at BCCH, Surgical Oncology and Surgical Reconstruction, within a larger aim of developing the areas that would result in integrated and cohesive planning for resources that could be leveraged to support the work of all members of the Department of Pediatric Surgery. Continued progress in the development of the Oncology program provided sufficient variety, volume, complexity, research and educational opportunities to be an area of strategic importance. Surgical Reconstruction provided a similar opportunity, as all subspecialties within the Department of Pediatric Surgery have some type of simple to complex reconstruction. Surgical Reconstruction is highly resource intensive, involving significant levels of work and cooperation between subspecialties, as cases may require expertise from several areas.

Education

Education as it relates to medical students, residents, fellows, surgeons, allied care providers, families and patients is essential to the delivery of quality pediatric surgical care and improved outcomes. The Department recognized that educational initiatives must be supported at all levels through existing systems and mechanisms. The Department of Pediatric Surgery emphasized the importance of maintaining the volume and quality of surgical training experiences to provide for medical students, residents and fellows training requirements.

Evaluation

Evaluation of health services, health outcomes, policy and practices, and new technology is intrinsic to the delivery of quality surgical care and improved outcomes. Care agencies and providers require this information to develop and support changes in quality improvement initiatives. A lack of research providing information on health services, outcomes, new technology and expenditures as they relate to pediatric surgery was identified. The Office of Pediatric Surgical Evaluation and Innovation (OPSEI) was proposed to address this need.

OPSEI

OPSEI was an initiative of the Department of Pediatric Surgery at BCCH, in collaboration with the BC Research Institute for Children and Women’s Health and the University of British Columbia. OPSEI supported the development of clinical outcomes research, the implementation of quality improvement programs and analysis of issues surrounding the introduction and use of surgical technology in pediatric surgery.

OPSEI’s initial objectives were to:

  1. Launch the Department of Pediatric Surgery,
  2. Create a Simulation Project, to address critical utilization and access issues for pediatric surgery,
  3. Assess the implementation and outcomes of new surgical technology,
  4. Address critical patient navigation issues within surgical clinics,
  5. Advance and communicate pediatric surgical discoveries,
  6. Strive for excellence in pediatric surgical education for medical students, residents, fellows, and visiting surgeons,
  7. Facilitate collaborative clinical research, emphasizing randomized clinical trials that evaluate standard and innovative surgical therapies and surgical devices,
  8. Support the development of new analytical methods for evaluating surgical treatments,
  9. Advance innovation in surgery by creating a better understanding of practice,
  10. Conduct quality of care studies that focus on surgical error reduction,
  11. Investigate the health policy implications of research findings,
  12. Educate new investigators in the surgical services research,
  13. Partner with other centers in B.C.,
  14. Strengthen and expand high quality, interdisciplinary clinical evaluative and policy research and to carry on national benchmarking.

Strategic Framework

The strategic framework has structured the initial objectives for OPSEI to align and focus activities in three key areas: Evaluative Research, Education and Development, and Policy Creation. Evaluative Research emphasizes operations research and analysis to support the delivery of accessible, high quality, cost-effective pediatric surgical care to children and their families in B.C. Education and Development advances and communicates the knowledge base of pediatric surgeons in B.C., contributes to the national body of knowledge, and participates in the global development of knowledge and skills. Policy Creation contributes to a stronger Canadian research and innovation capacity, by providing leadership and the development and implementation of policy related to pediatric surgery.

Structure

As a program of the Department of Pediatric Surgery at BC Children’s Hospital, the Board of Directors of OPSEI included the Heads of each Division of Pediatric Surgery, the Chief of Pediatric Surgery, and a faculty representative from UBC. The OPSEI Board has annually reviewed the vision, strategic plan, goals, program budget and structured growth of OPSEI. OPSEI staff have included a Medical Director, a Managing Director, an operational research analyst and an academic administrative assistant.

Finance

OPSEI has been very successful in attracting funding and resources for pediatric surgery. Contributions have been made by the UBC Department of Surgery, the UBC Department of Orthopedics, the Department of Pediatric Surgery at BC Children’s Hospital, the Provincial Health Services Authority and the BC Children’s Hospital Foundation. Grant funding from various sources has also been received. In total, 71 % of the funding was from donations, 16% from operations and 13% from grants.

In its first year of activities, OPSEI conducted a series of projects and activities to support the achievement of its three primary goals. Under Evaluative Research, a real-time priority wait list tool was created, using a computerized mathematical formula that ranks patients based on a priority category and current wait time. Operational Simulation technology was used in the Emergency Department, the Orthopedic Clinic and the General Surgery clinic. A technology assessment framework to assess the financial, operational, and educational requirements for new pediatric surgical techniques was put into place.

Under Education and Development, OPSEI developed educational vignettes with the Knowledge Network, highlighting surgical innovations and to be aired on the Knowledge Network. A grant was obtained to provide and implement a specialized practicum for the nurses and students in the OR and the Intensive Care Unit as a means of attracting new graduates to the hospital. A Global Health Education curriculum was developed for students seeking opportunity to work in developing countries. A new medical summer student preceptorship was developed to help students learn clinical and research methodologies. This program continues to be hugely successful. Guest lecture series were given monthly on innovation and emerging pediatric surgical techniques. Community projects for students were established, integrating the principles of social responsibility as an essential component of learning for medical students.

Under Policy Creation, OPSEI has contributed “The Priority Wait List Tool” to the National Pediatric Wait Time Strategy. BCCH also brought expertise in developing a national wait list management tool and has been instrumental in uniting the pediatric surgical departments across Canada. The Department of Pediatric Surgery is a founding member of the coalition of sixteen academic health care institutions with Pediatric Surgical programs advocating for improved access to care through various initiatives.

Summary

The Office of Pediatric Surgical Evaluation and Innovation has celebrated ten years of activity and has proven to be a very important element in the vision of the Department of Pediatric Surgery at BCCH. Achievements in relation to Evaluative Research are significant and encouraging. To date, a level of analysis provided by the program and not previously available has contributed to improvements in patient flow and decreased surgical wait times in clinical areas. More comprehensive information has also strengthened decision making regarding resource requirements and improvements. The web-based, Real Time Priority Wait List Tool significantly improved management of pediatric surgical wait list and wait times at BCCH and provided a national prototype. Achievements in Education and Development, including the Pediatrics Surgery vignettes, the summer student preceptorship, and the OPSEI lectureship series, have contributed to the body of knowledge and local expertise. The program’s additional emphasis on pediatric surgical and child health issues internationally was achieved through the global health education program, which supported many international surgical “camps” overseas as well as rural projects. The program’s achievements in Policy Creation hold tremendous promise. Participation in a national pediatric wait time strategy in the Pediatric Surgical Chiefs of Canada has provided opportunity to lead the development of national strategies to improve access to Pediatric Surgical Care.

All in all, the creation and development of OPSEI over the last ten years has been extremely successful in the support and achievement of the Department of Pediatric Surgery at BCCH.