Improving the quality of life of patients and families begins with a sense of support and a seamless experience between institutions. A number of projects have been developed within the scope of MUSCO to allow patients and their families to feel supported and to streamline and facilitate the corresponding administrative procedures. This involves providing tools and resources to improve logistics and families’ experiences throughout their care trajectory.

MUSCO Projects

Inter-establishment Coordinators

Educational Technology

Relay

Patient Trajectory

AMS Pathway Review

Collaboration

Patient Trajectory

Project leader

Kelly Thorstad Director of Nursing and Patient Services, Shriners Hospitals for Children — Canada

The project

Define a clear, transparent process for transferring patients

MUSCO Strategic Goal

Guide the patients and their families toward the appropriate care and services.

Project Objectives

1

Define a clearer and more understandable pathway for patients
2

Provide better access to information for families, enabling them to better understand their child’s health status and the healthcare system
3

Enable families to identify available resources more effectively and provide them with all necessary documentation at the time of admission
4

Improve access to patient-specific care with the appropriate specialists
5

Provide more effective care and treatment for patients in the short, medium and long term
6

Improve the patient experience and family satisfaction, including facilitated planning for families

Progress Report

Brainstorming sessions to identify solutions

The project is divided into four phases and is currently in Phase 3:

Phase 1 : Needs analysis: Diagnosis of existing pathways and data collection from professionals and families
Phase 2: Co-creation of solutions
Phase 3 : Implementation of solutions and monitoring of changes in clinical and organizational processes
Phase 4 : Evaluation of the impact on patients/families, professionals, institutions and the healthcare system, and adjustments to the solutions as required

A research and evaluation process called My Way/Mon Chemin has been developed under the scientific direction of Dr. Marie Beauséjour to support several of these phases to help achieve the stated objectives. It had been being supported by local reseach teams supervised by Dr. Stefan Parent (CHU Sainte-Justine), Dr. Argerie Tsimicalis (Shriners Hospitals for Children — Canada) and Dr. Janet Rennick (Montreal Children’s Hospital) who, as local contributors, enabled the implementation of the project in each of the partner institutions. This study was also based on an integrated approach with the social design agency Meilleur Monde.

In Phase 1 and 2, the following key actions were completed:

Several workshops and analyses led to the mapping of the cross-institutional pathways for three care profiles: (1) spinal surgery, (2) general orthopedic surgery for patients with a motor developmental disorder, and (3) rhizotomy
Several efforts have allowed to obtain the first approvals from different ethics committees of the various institutions. Data collection has been conducted in each of the facilities, and focus groups have been organized with professionals to complement questionnaires, as well as individual interviews with families identified as having a care pathway relevant to the study
In parallel to this crucial stage of data collection and individual and/or group interviews, the working group has identified Quick Wins to be implemented. These have been rolled out within the institutions by the Inter-establishment Coordinators (IEC)
Brainstorming sessions were held to identify solutions based on compiled observations, and to prioritize solutions that will effectively address integration challenges, duplication and unmet service needs.

Six solutions considered “important,” “supported by evidence” and “easy to implement” were prioritized and presented to hospital administrators:

Create a committee to manage inter-institutional pathways
Systematize the pre-operative courtesy call
Expand post-discharge calls to all institutions
Systematize the scheduling of multidisciplinary appointments for initial consultations
Strengthen the role of the IEC
Implement the 4 way information sharing protocol

A permanent Inter-Establishment Trajectory Management Committee (ITMC) has been set up to manage inter-institutional pathway and is assuming responsibility for ensuring the implementation of the other five solutions as well as any other projects that address issues relating to inter-institutional pathways.

Working Groups :

Alison Leduc
Androniki Tsoybariotis
Annie Castro
Annie Pinet
Aurélie Vigné
Camille Brosseau
Caroline Marie Fidalgo
Caroline Shaw
Gwenaelle Trottet
Kelly Thorstad
Maria Alexiou
Marie-Annie Lagacé
Marie-Eve Chevrette
Stéphanie Gould
Soo Lin Ng
Valérie Vermette

Central and local research teams :

Argerie Tsimicalis
Carolina Martinez Jaramillo
Christine Gannon
Isabelle Turgeon
Janet Rennick
Liset Maria Rodriguez
Marie Beauséjour
Martin Sasseville
Nathalie Jourdain
Sofia Addab
Ya Ning Zhao