Open Hand Introductory PDSA

Some of you may have learned to play bridge as children, with your parents or maiden aunts!! If you did, then you may remember the concept of playing an "open hand", where everyone lays his or her cards on the table, and we observe and discuss why and how we do each thing - why we bid this, why we led that, why we played that card, etc. That's more or less the way we conducted the first PDSA cycle. All partners who wished to be involved were included.

We chose a somewhat modest problem as a first PDSA cycle to undertake. It is specific to Ontario, and falls within the scope of the Health Services team. We chose it because it is a time-limited opportunity that we think will provide an uncomplicated example of what we are trying to do, and will translate well to other jurisdictions.

PROBLEM	One of the major impediments to good primary care for people with disabilities is not being able to access the examining table in the doctor's office
AIM	To increase accessibility of family physician's examining rooms for people with mobility disabilities by ensuring availability of adjustable examining tables and ceiling track lifts
OUTCOME	To include these two items in business plan for each of 50 new FHT's as start-up costs

STAKEHOLDERS:

Academic Partners	Community Partners (Specific people approached)	Policy Partners (Specific people approached)
Academic Lead - CURA Secretariat Health Services Team Lead	Anne Johnson Health Station Canadian Paraplegic Association - Ontario Ontario SCI Alliance 4 regional SCI Alliances Canvass other partners	FHT Team - Ontario Ministry of Health & Long Term Care AODA Built Environment people - Ontario Ministry of Community and Social Services

What Do We Know:

There is consistent evidence that the most significant physical barrier to access for people with mobility impairments (assuming they can actually get in - ie. No stairs!) is lack of an accessible examining table and lift to permit patients to be examined. There is Ontario-based research (Bugaresti, McColl) showing that only about 15% of practices have this. There is no financial assistance to permit family physicians to acquire this equipment (totalling approximately $10,000). There are accessibility standards for family medicine in Canada, and for Family Health Teams in Ontario, but neither have ever been enforced as primary care practices are officially "private" clinics even though they are funded through public means.

What Do We Need To Know:

• When are the next 50 FHT's being announced? When will their business plans be finalized? Etc.

PLAN	Academics work with community partners and policy partners to fashion knowledge products that meet the need for evidence; choose an advocacy approach with partners and assemble the most pertinent evidence for the target audience - Ministry Primary Care Team
DO	Community partners interact with policy partners to create receptivity for evidence and to mobilize knowledge to persuade Ministry to approve funding for equipment in FHT budgets; assist FHT's to know what to ask for in their budget requests.
STUDY	Academic partners figure out how to monitor outcomes of knowledge mobilization, in order to learn from DO cycle and then
ACT	More broadly undertake the KT strategy

How did this "Open Hand" play out?

The Open Hand PDSA is still in progress, but here is an account of what has been done so far.

PLAN:

The planning stage included:

• Assembling what we knew about the issue in a user-friendly one-page document that could be used to communicate the issue with a variety of interested stakeholders (see this document here).
• Contacting our policy partner, at the Ontario Accessibility Directorate (MCSS), who advised us that the Customer Service Standard for the Accessibility for Ontarians with Disabilities Act (2005) had come into effect on January 1, 2010, and as a result, physicians offices might be considered part of the broader public sector, and therefore might be required to comply.
• Contacted the MOHLTC's Team Lead in charge of Family Health Teams to inquire what had happened to the accessibility guidelines for FHT's that I had helped them to write about 2 years ago, and where they were at in terms of accessibility expectations of FHT's.
• Her colleague with expertise in this area returned my call, and advised that the accessibility guidelines were expected to be released any day. The hold-up was related to reconciling with AODA and French-language translation. He felt that the Ministry was very keen for FHT's to be fully accessible, and that they would be open to receiving budget requests for accessibility upgrades in the coming budget cycle. He suggested that we conduct an accessibility scan of the existing 169 FHT's to see if they needed assistance/consultation in assessing their accessibility needs. He suggested ways of contacting the FHT's that would be the most efficient.

DO:

The PDSA was then handed off to community partners who used their advocacy skills, connections and their networks to make real changes that will benefit people with disabilities. In this case the Ontario SCI Alliance worked through their regional networks to contact individual FHT's to discuss helping them make their premises optimally accessible.

STUDY:

The study phase will involve the Academic partners taking the lead on monitoring the impact of these actions on the Family Health Teams, on disabled patients, and on our member organizations with the help of Community partners. The academics will use the information learned to develop a tool kit for broader dissemination and advocacy.

ACT:

The action phase will extend our work outwards to other partners within our own group, to other disability types, to other primary care models, to other provinces and jurisdictions. Lessons learned will be shared with all of the CDPA teams for incorporation in their own individual PDSA cycles.