Bonnyville Health Centre, Alberta

Pizza in Rural Canada: The Great Leveler

by James Ruiter, MD
(From: Birth Models that Nurture Cooperation between Professionals: Pizza and Other Keys to Disarmament. In Birth Models on the Edge: Finding Solutions to Global Controversies.
Ruiter, P. James A., and Cameron, Carol; Betty-Anne Daviss and Robbie Davis-Floyd, Eds. Berkeley and London: University of California Press. Forthcoming 2016).

Bonnyville, a Small Town of 6,000 inhabitants

“The first site that we consider to be a model of the successful implementation of the MOREOB program is a rural hospital in Bonnyville, a small town of 6,000 inhabitants in northeastern Alberta, Canada. A small number of family physicians provide obstetric services to this community where the hospital is classified as a Level 1 site, and serves a greater population of about 20,000. “Level 1” in Canada means that there is no special care nursery, and therefore management of pregnant women is aimed at those of 36 weeks’ gestation and more.
We began identifying gaps in our knowledge that prevented us from advancing our unit’s quality and safety performance.The Bonnyville area is the home to several First Nations’ (aboriginal) communities, groups traditionally close to the land and nature, yet with an historical oppression from the dominant white settlers, including the imposition of a medical model of birth. As our team progressed through the MOREOB Program, we began identifying gaps in our knowledge that prevented us from advancing our unit’s quality and safety performance. Simply creating a venue where we could all sit down and talk about the obstetrical care we were providing to our community could fill one of those gaps. While the program “forces” some of this function, it also guides the creation of Front-Line Ownership (Zimmerman_Matlow_FrontLineOwnership_HealthcPapers_2013_69). In so doing, it creates a community of practice that is empowered to seek local solutions to local problems.

Pizza Fridays

We wanted to meet more often, on a voluntary drop-in basis. “Pizza Fridays” followed the adage of: “Feed them and they will come.” One of our physicians sponsored two pizzas for the monthly meeting. Everyone would be welcome to sit down, disarm, and chat. The boardroom, conveniently located just down the hall from the unit, was purposely chosen as the site of these events, as the nurses could easily attend if they managed a break. At first we created a small agenda in case no one wanted to or felt safe to speak, but it quickly became obvious that this precaution would not be necessary. They came early (so as to not miss at least one slice of pizza) and they came from everywhere—nurses, family doctors, pharmacists, and even our colleagues from Environmental Services. We were all on a level playing field. We learned much about each other and from each other. We shared great ideas for improvements in safety, quality, and practice. This venue was a resounding success, and allowed us to actually reduce the work necessary to run the unit. With this small step, the unit began to run itself.

With this small step, the unit began to run itself

We created another venue following the success of the first. After 20 years, I was leaving the community. I had given one year’s notice for the community to be able to find a replacement. Performing the lion’s share of obstetrics, for years I had been trying to create a “shared care” model for sustainable rural obstetrics, to no avail. My impending departure now pushed the medical community into action, and a shared care model was born. Creating this new model led to the need for improved communication between the “shared-care on-call delivering practitioners” and the Public Health providers, including the Aboriginal communities’ health providers. We knew we possessed critical information they needed, and vice-versa. As a result, we created a weekly Monday morning handover round where this wealth of information could be quickly shared, and updated. As a result, overall workload and phone calls decreased, and quality increased.
At the same time, pushback was occurring at my clinic. Frustration with perceived bad behaviour on the part of some patients had reached a boiling point with the staff. “No-shows” are patients with an appointment who do not show up for that appointment, resulting in other patients being unable to access care and creating a backlog in the community. This problem is particularly important in an underserviced area such as Bonnyville because it leads to an overuse of the Emergency Department. It also resulted in a new policy of posting signs threatening penalty fees for this perceived bad behaviour. Since a proportion of these no-shows came from the Aboriginal community, I realized that I needed to use what I could no longer ignore: the strategies of communication and teamwork that MOREOB had taught us.

First Nations Women

Genuinely concerned that many First Nations’ women were not getting adequate prenatal care, I suggested that we meet with the representatives of the band to understand the barriers in keeping those appointments. Some met the idea with skepticism, but I went anyway. The First Nation’s Health Services nurse, Gisèle Gagné, who felt strongly that a real solution was within our grasp, facilitated the meetings. To the surprise of most, these meetings led to a much clearer understanding of the barriers to success.
"We needed to redesign the way prenatal care was being provided to the First Nations’ women."First, we realized that a real “outside the box” approach was necessary: we needed to redesign the way prenatal care was being provided to the First Nations’ women. In cooperation with the pregnant women of the reserve, the band elders, First Nations Health Services, and the Bonnyville Primary Care Network (An Alberta Government initiative encouraging Health Regions and local medical staff to create joint ventures for local health improvement and improved access), we took the elements of information that pregnant women on the reserve wanted to learn about, and the elements that we, as practitioners, wanted them to know about, and redesigned the prenatal surveillance model to provide prenatal care onsite instead of at the doctor’s office.
We called it the Kehewin Project. Launched on April 8, 2008, this project’s goals were:
1.Improved access to prenatal care for the women (thereby reducing the need for visits to the Emergency Room);
2.Improved maternal and infant outcomes, reduced alcohol and tobacco use, and reduced family violence (self-reported);
3.Softer outcomes sought were an increased sense of community and support among the women of the band;
4.We also sought the involvement of more male partners to better prepare them for their role as fathers.

The Kehewin Project

This project was a combination of opportunity, circumstance, and vision. The new model of care resulted in a significantly increased number of prenatal visits by the First Nations’ women, as well as increases in initial cervical swabs and blood testing. Focus group evaluation demonstrated increased confidence by the women, increased transferability of knowledge and skill, and better relationships with the nurses and staff at the Kehewin Health Centre. Prenatal women began to feel free to drop into the office anytime. Family friendly community support also increased as employers in Kehewin began to agree to allow their pregnant staff to attend prenatal classes without consequence, another previously unrecognized barrier to the women meeting their appointments at the doctor’s clinic.
Other outcomes included an increase in the women’s trust of physicians, better relationships with the medical van driver (a driver hired to drive band members to medical or laboratory appointments), and better access to prenatal care and to the healthcare team. The women liked the greater involvement with doctors and appreciated the group approach of the new model, which allowed for more prenatal women to relate and share their stories. As part of the project, the women weighed themselves, used an automatic blood pressure cuff, and filled in their own charts. These empowering practices led to a clearer understanding of their own health. More prenatal women were seen before 12 weeks’ gestation—a strategic and important time for dietary counseling and substance use advice.
5% reduction in C-SectionsUltimately, a reduction in cesarean birth ensued (from 21% down to 16%). The women gained skills in taking care of their own health as well as in craftwork, which occurred at every session of prenatal classes while they waited for each other to be seen in private by the physician or nurse. Once all women were seen in private, the circle interactive and supportive session would begin. Women, their partners, and, with permission, the medical team would share the questions that were raised in private by the women. Women who had had previous experience in pregnancy were encouraged to answer, and the medical team only became involved in the answer if there was need to redirect based on evidence, etc. At first few partners came and little was shared, but as time went on the sessions became immensely successful.

Other results included:

10 day reductionin ICU stays
A reduction in admissions and length of stay in the Neonatal Intensive Care Unit for infants requiring transfer for further care (from an average of 19 days down to only 9 days).
increaseof initial postpartum visits
An increase in the number of initial postpartum visits (from 64% to 81%).
The overall number of “no shows” throughout a woman’s pregnancy dropped significantly, as did the 
number of visits to the Emergency Room.
(Data on File: Kehewin Health Centre) 
At time of writing, February 2015, this program is still going strong, and continues to bring in more positive data.
Counter intuitively, a significant increase in self-reported alcohol (20% to 40%), tobacco (68% to 72%) and drug (29% to 44%) use occurred. Focus group discussion led to an understanding that these increases were a direct result of greater honesty in the women’s reports because of their increased trust in the healthcare team, suggesting increased reporting rather than increased occurrence. However, we are also aware that dependence on the medical world also translates into less self-reliance. 
Nevertheless, in the words of Dr. Lalonde, “The time and effort to create this program was rewarded by the decreased risk in the practice of obstetrics and medico-legal costs.” (André B Lalonde, Creation of a Program, personal collection, unpublished. 2012)”
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We can apply a similar approach to communication and teamwork that we bring to OB to adjacent maternal/infant care departments and even other hospital units such as emergency, ICU, cardiology, and other risk management areas.