Quality Improvement ideas

The following improvement ideas, with the exception of the physician wellness goals, are based on Choosing Wisely Canada. Each idea contains a link to the Choosing Wisely recommendation or best practice upon which it is based.

The OMA partnered with Choosing Wisely Canada, the College of Physicians and Surgeons of Ontario, OntarioMD, the Ontario College of Family Physicians and Ontario Health in this work with the objective of supporting members in navigating the CPSO’s Quality Improvement program.

The information provided here is for informational and educational purposes only. It should not be construed as clinical or legal advice and not relied upon as such. While we strive to provide accurate and up-to-date information, there is no guarantee of its accuracy, completeness, or applicability to a specific clinical situation.

Topic areas

Antibiotics
Benzodiazepines
Diabetes
Opioids
Pap smears
Proton pump inhibitors
Physician wellness

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Antibiotics

Improvement idea:  During cold and flu season this year, I will work with patients who present with bronchitis exacerbations to help them better understand that antibiotics won't help them feel better or improve their health. I will provide alternative ways to cope with their symptoms.

Intervention: I will verbally review the viral prescription for adults with patients who present with bronchitis. I will then fill out the viral prescription electronically or by hand and either scan or take a photo of it and email it to the patient or hand it to the patient, depending on their setup within our system. I will document patient conversations in the chart and monitor my use of antibiotics for this diagnosis.

Ways to support the intervention:  

Use your EMR to:

  1. Run a search to identify patients who presented with bronchitis within the past three months. Then, generate a count of these patients who were prescribed antibiotics and a count of patients who were given the viral prescription and compare the two groups
  2. Over the next three months, measure the change in your prescribing patterns by repeating your counts of patients who were prescribed antibiotics vs. the viral prescription

If you need help using your EMR for these tasks, contact support@ontariomd.com. 

If you prefer to get data about your prescribing patterns from outside of your EMR, you can review the Antibiotic section of your MyPractice Primary Care report, produced by Ontario Health. MyPractice Reports for Primary Care are refreshed twice per year (in June and December) and reflect data from nine months prior. For example, the report released in Dec. 2023 contains data up to March 2023. Since MyPractice Reports reflect historical data and patterns, they may be most useful to help you identify potential areas for quality improvement.

For support on how to use the MyPracticeReport data for Quality Improvement email oh-hqo_primarycare@ontariohealth.ca.

Resources to learn more:

Improvement idea: During cold and flu season this year, I will use specific criteria to decide if a patient requires treatment with antibiotics for an upper respiratory infection. If they meet the criteria for treatment, I will treat only for five days.

Intervention: I will record specific symptoms for patients suspected of having an upper respiratory infection. For patients not meeting the criteria for treatment, I will use a viral prescription for adults or a viral prescription for children ages three months and older. 

Ways to support the intervention:

Use your EMR to:

  1. Implement problem-oriented visit documentation templates to record symptoms and related details, and/or
  2. For patients who meet criteria for treatment with antibiotics, leverage the functions within your EMR prescription writer to ensure the prescription discontinues and falls off the active medication list after five days

If you need help using your EMR for these tasks, contact support@ontariomd.com. 

If you prefer to get data about your prescribing patterns from outside of your EMR, you can review the Antibiotic section of your MyPractice Primary Care report, produced by Ontario Health. MyPractice Reports for Primary Care are refreshed twice per year (in June and December) and reflect data from nine months prior. For example, the report released in Dec. 2023 contains data up to March 2023. Since MyPractice Reports reflect historical data and patterns, they may be most useful to help you identify potential areas for quality improvement.

For support on how to use the MyPracticeReport data for Quality Improvement email oh-hqo_primarycare@ontariohealth.ca.

Resources to learn more:

Improvement idea: When antibiotics for respiratory tract infections are indicated I will use a short duration.

Intervention: I will review the Cold Standard and adopt a five day antibiotic duration for sinusitis, pneumonia, otitis media (in children above two years) and COPD exacerbation when indicated. I will then review my prescription of antibiotics over the next three months to see if my prescriptions follow this recommendation.

Ways to support the intervention:

Use your EMR to:

  1. Leverage the functions within your EMR prescription writer to ensure the prescription discontinues and falls off the active medication list after five days for sinusitis, pneumonia, otitis media (in children above two years) and COPD exacerbation
  2. Run a search to identify patients who presented with sinusitis, pneumonia, otitis media (in children above two years) and COPD exacerbation. Then, review the duration of antibiotics prescribed to ensure that you are following the recommendation to adopt a five-day antibiotic duration

If you need help using your EMR for these tasks, contact support@ontariomd.com. 

If you prefer to get data about your prescribing patterns from outside of your EMR, you can review the Antibiotic section of your MyPractice Primary Care report, produced by Ontario Health. MyPractice Reports for Primary Care are refreshed twice per year (in June and December) and reflect data from nine months prior. For example, the report released in Dec. 2023 contains data up to March 2023. Since MyPractice Reports reflect historical data and patterns, they may be most useful to help you identify potential areas for quality improvement.

For support on how to use the MyPracticeReport data for Quality Improvement email oh-hqo_primarycare@ontariohealth.ca.

Resources to learn more:

Improvement idea: Decrease the number of unnecessary antibiotic prescriptions for asymptomatic bacteriuria.

Interventions: I will review the results of urine cultures from the past three months in my EMR and identify if asymptomatic bacteriuria was treated to understand my prescribing patterns. I will read the urological infections guideline and then follow this practice going forward.

Ways to support the intervention:

Use your EMR to:

  1. Run a search to identify non-pregnant patients who presented with asymptomatic bacteriuria in the past three months. Then, generate a count of these patients who were prescribed antibiotics
  2. Over the next three months, follow the urological infections guideline. Then, measure the change in your prescribing patterns by repeating your count of non-pregnant patients who were prescribed antibiotics for asymptomatic bacteriuria and compare it to your previous count

If you need help using your EMR for these tasks, contact support@ontariomd.com. 

If you prefer to get data about your prescribing patterns from outside of your EMR, you can review the Antibiotic section of your MyPractice Primary Care report, produced by Ontario Health. MyPractice Reports for Primary Care are refreshed twice per year (in June and December) and reflect data from nine months prior. For example, the report released in Dec. 2023 contains data up to March 2023. Since MyPractice Reports reflect historical data and patterns, they may be most useful to help you identify potential areas for quality improvement.

For support on how to use the MyPracticeReport data for Quality Improvement email oh-hqo_primarycare@ontariohealth.ca.

Resources to learn more:

Improvement ideas: Decrease the number of unnecessary urine cultures by not systematically sending a urine culture on asymptomatic patients. Only send a urine culture if there is a treatment failure or a recurrence (less than one month) or specific risk factor for a complicated UTI.

Intervention: I will do a chart review of asymptomatic patients in the past three months and count how many had a urine culture that was in retrospect not warranted. I will continue to track the number of urine cultures ordered for asymptomatic patients over the next three months and compare to the previous rate.

Ways to support the intervention:

Use your EMR to:

  1. Run a search to identify asymptomatic patients who presented in the past three months. Then, generate a count of these patients who were ordered urine cultures
  2. Implement problem-oriented visit documentation to assess and record UTI information to determine urine culture eligibility
  3. Over the next three months, implement your intervention and then measure the change in your urine culture orders for asymptomatic patients

If you need help using your EMR for these tasks, contact support@ontariomd.com.

Resources to learn more: 

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Benzodiazepines

Improvement idea: Identify patients with insomnia currently taking benzodiazepines for whom deprescribing should be considered. Develop a practice strategy for deprescribing based on identified patients (e.g., discuss other possible treatment options for insomnia with adults currently on benzodiazepines who come in for an appointment or when performing routine medication reconciliation).

Interventions: I will add a reminder in the EMR of older adult patients who have been prescribed benzodiazepines for insomnia to explore other treatment options, such as sleep restriction therapy. I will provide a benzodiazepines brochure to these patients (at the appointment, by mail, email or other) and explain the benefits of reducing benzodiazepine use. I will organize follow-up of these patients and document how much counselling I have done and how many patients achieved a reduction in their use of benzodiazepines.

Ways to support the intervention:

Use your EMR to:

  1. Run a search to identify older adult patients who presented with insomnia within the past three months. Then, generate a count of these patients who are currently prescribed benzodiazepines. Alternatively, if you are on an eligible EMR and already enrolled, you can leverage medication management within the i4C Dashboard to review patients currently prescribed benzodiazepines. Use i4C Dashboard indicator MED-PSY-003: Benzodiazepines Prescribed. Learn more about i4C Dashboard indicators. Note that to access i4C Dashboard you must have an existing license. New licenses are no longer available                                                                     
  2. Create EMR tools that can alert you at the point of care to identify patients currently taking benzodiazepines
  3. Over the next three months, implement your interventions and then measure the change in your prescribing patterns by repeating your count of older adult patients who were prescribed benzodiazepines for insomnia

If you need help using your EMR for these tasks, contact support@ontariomd.com. 

If you prefer to get data about your prescribing patterns from outside of your EMR, you can review the Opioids section of your MyPractice Primary Care report, which also identifies benzodiazepine prescribing patterns, produced by Ontario Health. MyPractice Reports for Primary Care are refreshed twice per year (in June and December) and reflect data from nine months prior. For example, the report released in June 2023 contains data up to September 2022.

For support on how to use the MyPracticeReport data for Quality Improvement email oh-hqo_primarycare@ontariohealth.ca.

Resources to learn more:

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Diabetes

Improvement idea: Decrease overtreatment of diabetes in adults (mainly older adults) by not relying on strict HbA1c targets.

Interventions (choose one or more): I will aim for an HbA1c between seven and eight per cent in most adults and I will deintensify the medication regimen of those with an HbA1c of 6.5 per cent or less. I will avoid targeting an HbA1c while minimizing symptoms of hyperglycemia in patients with a life expectancy of less than 10 years.

For older adult patients diagnosed with diabetes, the ranges of HbA1c that you should aim to achieve are: 

  • 8.0 – 8.5 per cent in those with multiple morbidities and shorter life expectancy,
  • 7.5 – 8.0 per cent in those with moderate comorbidity and a life expectancy < 10 years,
  • 7.0 – 7.5 per cent in healthy older adults with long life expectancy

Ways to support the intervention

Use your EMR to:

  1. Run a search to identify elderly patients who are diagnosed with diabetes, or if you are on an eligible EMR and already enrolled, leverage chronic disease management within the i4C Dashboard to review the patient’s latest HbA1c results
  2. Embed EMR tools (where possible) that can alert at point of care to identify the patient’s age and latest Hb1ac result
  3. Perform diabetes medication reviews and make adjustments as appropriate

If you need help using your EMR for these tasks, contact support@ontariomd.com. 

If you prefer to get data about your prescribing patterns from outside of your EMR, you can review the Diabetes section of your MyPractice Primary Care report, produced by Ontario Health. MyPractice Reports for Primary Care are refreshed twice per year (in June and December) and reflect data from nine months prior. For example, the report released in June 2023 contains data up to September 2022.

For support on how to use the MyPracticeReport data for Quality Improvement email oh-hqo_primarycare@ontariohealth.ca.

Resources to learn more

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Pap smears

Improvement idea: Stop doing Pap smears on those who have had a hysterectomy for non-malignant disease.

Intervention:  I will add a note in the EMR for patients who have had a hysterectomy for non-malignant disease that they do not need a Pap smear.

Ways to support the intervention:

Use your EMR to:

  1. Run a search to identify patients who are age appropriate (i.e. 25 to 69 years of age according to Choosing Wisely Canada) and have had a full hysterectomy for non-malignant disease. Then, generate a count of those patients for whom Pap smears are still being ordered. Alternatively, if you are on an eligible EMR and already enrolled, you can leverage preventive healthcare within the i4C Dashboard to review patients eligible and excluded for cervical cancer screening. Use i4C Dashboard indicator PHC-CAN-003: Patient Care Cervical Cancer Screening. Learn more about i4C Dashboard indicators. Note that to access i4C Dashboard you must have an existing license. New licenses are no longer available. 
  2. Enter Pap screening exclusions within the EMR for patients who have had a full hysterectomy for non-malignant disease
  3. Create EMR tools that can alert at point of care to identify patients not eligible for Pap screening due to having had a full hysterectomy for non-malignant disease
  4. Over the next three months, implement your intervention and then measure the change in number of Pap smears for patients with a full hysterectomy for non-malignant disease

If you need help using your EMR for these tasks, contact support@ontariomd.com. 

If you prefer to get data about your Pap smear patterns from outside of your EMR, you can review the Cervical Cancer Screening section of your Screening Activity (SAR) report and/or the Cancer Screening section of your MyPractice Primary Care report, produced by Ontario Health. MyPractice Reports for Primary Care are refreshed twice per year (in June and December) and reflect data from nine months prior. For example, the report released in June 2023 contains data up to September 2022.

For support on how to use the MyPracticeReport data for Quality Improvement email oh-hqo_primarycare@ontariohealth.ca.

Resources to learn more:

  • This idea is based on the following Choosing Wisely reference: Family Medicine (number four)

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Proton pump inhibitors

Improvement idea:  Assess the appropriateness of PPI for patients coming in over the next three months who have been taking a PPI for longer than eight weeks.

Intervention: I will add a note in the EMR patients taking a PPI for ≥ 8 weeks and reassess with the guidance of a standardized tool. 

Ways to support the intervention:

Use your EMR to:

  1. Run a search to identify patients who presented with gastrointestinal symptoms within the past three months. Then, generate a count of these patients who are currently prescribed long-term proton pump inhibitor (PPI) therapy (longer than eight weeks)
  2. Create EMR tools that can alert at point of care to identify patients currently on long-term proton pump inhibitor (PPI) therapy (longer than eight weeks). As appropriate, complete medication reviews and adjustments for these patients
  3. Over the next three months, implement your intervention and then measure the change in the number of patients on long-term proton pump inhibitor (PPI) therapy

If you need help using your EMR for these tasks, contact support@ontariomd.com. 

Resources to learn more:

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Physician wellness

Improvement idea: I would like to have a set of professional boundaries that I can consistently enforce to protect my time and energy.

Intervention (choose one or more): 

  • I will draft three to five professional boundaries; I will seek feedback on these boundaries from colleagues; I will continue to refine them over time. To develop boundaries, reflect on questions such as, “What would be possible if I did less of x and more of y?”, “What am I stopping to take on that new work?” or “How would a friend reflect on how I’m handling my competing demands?” Answers to these types of self-reflective questions can guide the development of your boundaries
  • I will learn more about self-compassion and connect with colleagues around this issue by taking a course on self-compassion for healthcare communities

Ways to support the intervention:

Find a colleague who can act as a mentor for you regarding work-life balance and boundary setting.

To measure the impact on your well-being, you could pick a measure to track before and after implementing your boundaries. For example, track your energy levels on a scale of one to ten for one week before implementing your boundaries, and then for one week afterwards. Other items to consider tracking include the number of times you are able to take a break for lunch during the workday or be home for dinner, or another benefit that setting boundaries may allow you to realize. You could also pick a measure related to patient care. For example, you could track the level of engagement you feel with patients, or your energy levels during your last patient appointments of the day before and after implementing boundaries.

If your intervention was to take a course on self-compassion, you could pick a measure to track before and after taking the course.

Resources to learn more

Improvement idea: I would like to have 30 minutes to eat lunch every day.

Intervention (choose one or more): I will block off 30 minutes in my calendar each day between noon and 12:30 p.m. for lunch; I will not schedule any patient appointments after 11:45 a.m.

Ways to support the intervention:

Review your calendar to see if this is something you are already doing. Mark each time you successfully take a lunch break in your calendar and then review after each month to see if you have met your goal. Share this goal with your administrative staff or office manager and ask them to ensure this time for lunch is blocked off daily.

Resources to learn more:

Improvement idea: I would like to connect more with my colleagues.

Intervention (choose one or more): I will create a buddy system with one of my colleagues; I will go for a 15 minute coffee break with a colleague at least once per week; I will go for a 15 minute walk with a colleague at least once per week. 

Ways to support the intervention:

Review your calendar to see if this is something you are already doing. Mark the time you connect with your colleagues in your calendar and then review after each month to see if you have met your goal. Reflect on whether this goal is helpful for you after a set amount of time and evaluate whether you want to continue with this activity.

Resources to learn more:

Improvement idea: I would like to build a mindfulness practice into my day/week/month.

Intervention (choose one or more):

  • I will explore mindfulness/self-compassion exercises and find one that resonates with me to try for two weeks to find out if it is effective
  • I will listen to my favourite music or a mindfulness app on my way to work
  • I will book a massage for myself once per month

Ways to support the intervention:

Review your calendar to see if this is something you are already doing. Each time you do a mindfulness activity, mark it in your calendar and then review after each month to see if you have met your goal.

Resources to learn more:

Improvement idea: I would like to get home in time to have dinner with my family.

Intervention (choose one or more):

  • I will not schedule any patient appointments after 4:45 p.m. (if 4:45 p.m. is too late for you, you can shift this time frame to whatever would suit your goal time for getting home for dinner)
  • I will delegate more administrative work to my staff to free up time

Ways to support the intervention:

Review your calendar to see if this is something you are already doing. Mark the times you have dinner at home in your calendar and then review after each month to see if you have met your goal.

Resources to learn more:

Improvement idea: I would like to improve the quality and/or quantity of my sleep.

Intervention (choose one or more): I will review sleep strategies and implement one that works for me over a period of two weeks to find out if it positively impacts my sleep and how rested I feel when I wake up. 

Ways to support the intervention:

Use a sleep diary. Rate the quality of your sleep on a scale of one to five for a week after you wake up. Review your sleep diary after each month to see if you have met your goal.

Resources to learn more:

Wellness resources

The CPSO has identified a number of wellness resources to support you.

Access these wellness resources

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