Dr. Joe Costa leads efforts to streamline referral process to musculoskeletal consultation and care

The delivery of timely care for patients with elective orthopaedic conditions in Northern BC remains challenging for many reasons. The Northern Health Authority (NHA) serves a population of approximately 288,000 which is spread out over an area covering almost 2/3 of the province of BC. Many of these patients belong to remote communities, and frequently travel long distances to receive care as access to services in their home communities is often limited. With only 11 full-time orthopaedic surgeons practicing in Northern BC, and few other physicians with expertise in managing musculoskeletal conditions, orthopaedic surgeons in the North struggle to manage the large volume of referrals they receive for patients in need of expert musculoskeletal advice and care. In addition, referring practitioners facing confusion about referral processes and surgeons’ individual wait times, often struggle to determine how best to refer patients to ensure they receive the right care, in the right place, by the most appropriate physician.

Recognizing the above challenges, the orthopaedic surgeons at the University Hospital of Northern British Columbia (UHNBC), and a team of over 30 stakeholders in the NHA, have embarked on an initiative to implement a central intake model for elective orthopaedic referrals in an effort to streamline the referral process, and to improve access to musculoskeletal consultation and care. The effort, led by UBC Orthopaedics Clinical Instructor, Dr. Anthony (Joe) Costa, is now well underway. The team has started the process of merging UHNBC orthopaedic surgeons onto one common electronic medical record (EMR) and adopting a single-page common referral form. The team has also made progress in adopting cohesive group branding, creating a central website for patients and referring practitioners, publishing a set of “orthopaedic referral guidelines”, implementing standardized x-ray order sets for elective orthopaedic referrals, and developing a non-operative arm to increase capacity to manage patients with non-operative orthopaedic problems. Funding for this initiative was provided by the Specialist Services Committee (SSC), a joint collaborative committee of the Doctors of BC and the BC Ministry of Health.

“There seems to be an ever-increasing focus on engaging physicians to identify and help address the many inefficiencies in our current healthcare system” says Dr. Costa. “Similarly, technological advancements in EMR systems and related IT infrastructure have made it possible to more easily collect relevant data, as well as communicate effectively between different IT systems.”

In addition to this initiative, Dr. Costa has also begun work on two other physician quality improvement (PQI) projects, focused on implementing standardized x-ray ordering for acute and chronic musculoskeletal conditions. The first project, supported through Dr. Costa’s participation in the new Virtual Action Learning Series (VALS) platform- a PQI initiative designed to teach physicians about quality improvement (QI) methodology- aims to implement consensus-generated, standardized, x-ray ordering at UHNBC, with the goal of reducing the proportion of x-rays that do not conform to consensus-generated guidelines for acute and chronic musculoskeletal conditions to less than 10% within 6 months. The PQI team for this project consists of physician representatives from orthopaedics, family practice, emergency medicine, as well as NHA radiology management, clerical staff, x-ray techs, PQI coaches, and patient partners! If successful, the hope is that consensus-generated, standardized x-ray ordering for acute and chronic musculoskeletal conditions will eventually be rolled out to all radiology sites within the NHA.

Dr. Costa’s second PQI project, builds off of the imaging project, and relies heavily on collaboration with the Interior Health Authority (IHA). The IHA is also in the processes of adopting a central intake model for orthopaedics, as well as implementing consensus-generated, standardized x-ray ordering for musculoskeletal conditions. This joint effort between the NHA and IHA, with support from the Specialist Service Committee (SSC), aims to establish a Return on Investment (ROI) for implementing consensus-generated, standardized, x-ray ordering for acute and chronic musculoskeletal problems. While this project is still in the early stages of planning, much groundwork has already been completed through the individual NHA and IHA orthopaedic central intake projects, as well as the respective standardized x-ray ordering projects.

While establishing an ROI for standardized musculoskeletal x-ray ordering is the main focus of this project, the greater hope is that the successful collaboration between two health authorities with similar goals of improving patient outcomes, patient and provider experiences of care, and reducing per-capita costs, will help foster the scale and uptake of similar initiatives throughout BC.

The PQI Initiative is one of two flagship programs of the SSC. The SSC represents a partnership between the Government of BC and Doctors of BC, and includes regular representation from health authorities. As such, the PQI initiative is co-designed in collaboration with all health authorities.

“Working on projects of this magnitude has been both incredibly rewarding, and incredibly challenging” says Dr. Costa. “As orthopaedic surgeons, we are exceptionally well trained with respect to our surgical skills and using traditional research methodologies, however we are often not as familiar with quality improvement type research methodologies, and rarely have exposure to the type of leadership training required to make these sorts of initiatives successful.”

Due to the increased availability of funding and support from organizations like the SSC, Doctors of BC, and the Ministry of Health, Dr. Costa believes that physicians are more likely to remain engaged and will ultimately be successful in implementing their change ideas. “Providing funding to undertake these types of projects, as well as providing interested physicians with learning opportunities to enhance their PQI and leadership skills can enable physicians to successfully lead change” he says.

When it comes to his research work, Dr. Costa sees an incredible opportunity to create change and make improvements in orthopaedic care delivery in the NHA and beyond. “Successfully leading change is mostly about getting people to buy-in, not only with their minds, but also with their hearts. Only when people truly believe that change is necessary, can a team come together, develop a vision, communicate that vision, and empower others to create more change.”

Learn more:

  • More information about centralized intake and the SSC initiative can be found here.
  • More information about the COA Position Statement on Access to Orthopaedic Care in Canada can be found here.
  • A preview of the new Ortho North Website can be found here. Password is orthonorth.

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