Tuesday, March 23, 2010

Dietitians at the Forefront of Primary Care Reform

There are currently 2.5 million Canadians with diabetes (CIHR, 2009). Currently only one-third of people with diabetes have preventive tests (e.g., foot or eye checks) done (CIHR, 2009). Fifty percent of the complications of diabetes can be prevented. In 2010, diabetes will cost $12.2 billion (CDA,2009). Diabetes is responsible for almost 10% of the total direct costs of the Ontario health care system (CDA,2009).

A gap exists between what we know and what we practice. The mission of the Hamilton Family Health Team (HFHT) Diabetes Learning Collaboratives is to close this gap. HFTF diabetes teams are made up of physicians, nurses or nurse practitioners, administrators and dietitians; some teams also have pharmacists. The majority of the team dietitians hold the Certified Diabetes Educators (CDE) credential and play an active role in the care of patients living with diabetes. We chose to implement practice improvements primarily through Learning Collaboratives.

Two Learning Collaboratives, each involving a number of HFHT practices, were launched in mid-2008. These focused around several face-to-face learning sessions. In-between structured learning sessions are ‘action periods’ during which teams use the Model for Improvement (Wagner, 1989) and the Care Model (Wagner, 1998) to redesign and improve the care delivery systems within their practices. The Model for Improvement is a strategy for testing, implementing, and spreading practice innovations. It includes use of plando- study-act (PDSA) cycles or rapid cycle improvement. The Care Model is a framework for an ideal system of healthcare for chronic conditions that can be used to identify areas for improvement.

Throughout the Learning Collaboratives, teams interacted with each other and with change facilitators, and by sharing reports. During action periods, a listserv was helpful for sharing tools and lessons learned, obtaining answers to questions, generating ideas for removing barriers, and identifying resources. Teams were expected to use data to monitor their improvement efforts. Every six months, team and aggregate clinical progress was assessed.

Results: Over a year there was an approximate ten percent improvement in number of patients with HbA1c, LDL, blood pressure and microalbumin tests completed, number of patients using an ACE or an ARB (blood pressure medications), and in patients having an LDL less than 2.0 mmol/L. We did not see significant clinical improvements in HbA1c results because we were bringing in patients who had not been seen recently and who had higher HbA1c results. This overshadowed improvements in other patients.

Learning: RDs were an integral part of each learning team. Because the individual RDs with the Hamilton Family Health Team often participate on many different physician teams, they were instrumental in sharing change strategies. For example, one RD was able to share how one of her teams had sent a letter to all their patients with diabetes, asking them to get bloodwork done only at laboratories that could share results electronically. This resulted in more visits being productive because the practice had already seen patients’ bloodwork. Many teams used this opportunity to address access to care for physicians and other providers (e.g., RDs, pharmacists).

Conclusions: Learning Collaboratives are an effective way to improve care. This process highlighted the role of the RD as information gatherer and sharer, change agent, and project coordinator leading to deeper trust and respect for the RDs on these teams and to greater job satisfaction for participating RDs.

For further information about Learning Collaboratives see www.improvingchroniccare.org.


Canadian Institute for Health Information. (2009). Diabetes Care Gaps and Disparities in Canada. 2009. Available at: http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=PG_2551_E&cw_topic=2551&cw_rel=AR_3191_E

Canadian Diabetes Association. (2009). An economic sunami: The cost of diabetes care in Canada. Available at: Accessed at: http://media3.marketwire.com/docs/cda207report.pdf Wagner EH. (1998). Chronic disease management: What will it take to improve care for chronic illness? Effective Clinical Practice, 1: 2-4.


Tracy Hussey, MSc, RD
Nutrition Program Manager
Hamilton Family Health Team
Hamilton, ON
T: (905) 667-4857

Tuesday, March 9, 2010

What Does it Take to be Successful in Our Work?

I have asked myself this question many times and the answer is not as clear or as straightforward as I would like it to be. Over time, what did become clear to me was that I was getting burnt out. How could I be good at what I did if I did not feel good about it?

According to Gallup Organizational Research, the characteristics of my “burnout” self is defined as “unengaged”. In a typical organization, 55% of staff members are unengaged, they demonstrate lower commitment, less connection with co-workers, more focus on activities instead of outcomes, and high stress. Engaged staff show support for each other and find more effective ways to accomplish their roles. Looking back, orientation is the ideal time to gain and maintain engagement in new staff.

I was aware that over the years there was little community nutritionist turnover and so there was no push to have formal development or evaluation of orientation. The role is equivalent to working as a sole-charge dietitian at the health unit without a practice leader providing leadership and support. As part of a Frontline Leadership course, I decided to survey my colleagues on their thoughts about their orientations and their perceptions of success at their work. Ten out of eleven nutritionists working with the adult population responded to a 10-item online survey.

The survey findings revealed the following perceptions about orientation:

  • 50% were not satisfied with the amount of orientation time

  • 70% felt that orientation did not prepare them to do their job

  • 50% felt they did not have clear expectations of their role

  • 70% felt they did not know what their coworkers expected of them

  • 50% felt that they knew what best resources or contacts to use when there were questions

  • during their first three months of work, 50% had weekly questions and 30% had daily questions re: their work/role

  • 90% felt having a mentor during the first year of work would have been helpful.

Respondents reported needing from one to five years to adjust to and to feel confident in doing their work. They had no concerns with the nutrition-related content aspects of their work; contextual considerations such as learning about the organizational structure, procedures and how the position related to other organizations and initiatives took longer to learn.

Lessons Learned

An orientation subcommittee was struck and suggested the following:

  • Establish consistent content and implementation of orientation.

  • Establish processes for providing initial and ongoing support.

    • Identify key contact person/coach.

    • Be able to check in regularly with the key contact person; have more opportunities to be together at the same site.

    • Develop a community of practice of dietitians (identify who can provide what kind of support and when).

  • Develop a list of competencies to provide the basis for development of individual learning plans.

We created a list of competencies specific to our work by combining examples from the Public Health Nutrition Framework and the College of Dietitians of BC Standards of Practice. Each competency outlines suggested activities to help enhance each skill area that a new hire can use to develop personal learning plans.

The project has uncovered areas around orientation never before addressed, in particular skill development and job satisfaction. After sharing the results with other community nutritionists working with other populations or programs, many identified similar experiences with their orientations. This led me to wonder how other community nutritionists without practice leaders address orientation and what kind of, if any, ongoing support they receive and/or provide.

Being successful in your work relates to being engaged. In turn, role clarity, clear performance expectations, positive environments, appreciative healthy relationships, and work enjoyment all influence engagement. These factors all impact client engagement, staff/peer relationships
and workplace business. Although the program managers (non-dietitians in our case) are responsible for providing information about what is required to succeed, orientation to facilitate success in the position, and coaching (including identifying strengths, areas for development and actions required), in reality they cannot. As community nutritionists, we need to take on these responsibilities to support each other and to do so on an ongoing basis. One way is to create a community of practice that fosters an environment of relationship building, and sharing of learning and innovation from like-minded colleagues who share common interests, challenges and expertise. Engaging in a community of practice can help those working solo to increase their understanding of their practice, and to develop strategies and knowledge more quickly and effectively.

Since completing this project, I have started a new position. Knowing what is needed to transition to a new job helped me direct my own orientation that included exploring communities of practice. I encourage new hires, particularly those in sole-charge positions, to advocate and implement the above strategies if they are not already in place. For me, having the awareness and the tools to maintain engagement is a small success.

Endsley S, Kirkegaard M, Linares A. (2005). Working together: Communities of practice in family medicine. Family Practice Management. Available at: www.aafp.org/fpm/2005/0100/p28.html


Vanessa Lam, RD
Vancouver Coastal Health
T: (604) 321-7051 (3331)
E: mailto:vanessa.lam@vch.ca