CQI in RSON enables cultural changes to facilitate healthcare system improvements

An RSON Series


The work of the Rural Surgical and Obstetric Networks (RSON) is split out into five pillars: Clinical Coaching, Continuous Quality Improvement, Remote Presence Technology, Evaluation, and Scope and Volume. In previous issues of BC Rural Update, we examined how the Evaluation Pillar intends to measure the impacts of RSON and how Clinical Coaching is improving both individual and team performances.

Over the next year, BC Rural Update will be featuring the work of each of these pillars, and will engage the providers leading each pillar to discuss the ongoing work taking place within these networks.

Continuous Quality Improvement (CQI) is frequently difficult to define succinctly – ask different providers what CQI means to them and you’ll likely end up with a wide diversity of answers. Within the context of the RSON project, CQI is used as a framework to create capacity in local rural surgical and obstetrical teams and provides supports to enable the transformational changes required to achieve a sustainable healthcare system. Dr. Sean Ebert – clinical co-lead of the CQI Pillar – notes that “the work we are doing is both complex and complicated and success will be dependent on collaboration and resource alignment between all stakeholders.” There are currently multiple health improvement initiatives taking place within British Columbia and RSON is well-aligned with regional and provincial priorities of accessible, equitable, sustainable and safe health care.

The CQI pillar is actively integrating the Measuring and Monitoring of Safety (MMSF, aka Vincent Framework) quality improvement framework into RSON with the aim of shifting culture towards a patient-centered, team-based safety focus prioritizing collective learning and developmental evaluation. 

The work of the CQI Pillar of RSON is best visualized as a three-legged stool

CQI activity within RSON is undertaken at the community level by a Core Team lead by a Best Practice Quality Nurse(s) (QN) that focuses on clinical outcomes, patient reported outcomes/experiences, and culture driven system changes. Each community Core Team is the key enabler of cultural change for their local group. Collectively these teams are working with Dr. Ebert and CQI Pillar administrative co-lead Karen Osiowy. RSON has also partnered with Salus Global to implement – MOREEX to teach local communities how they can best shift to a team-based quality improvement process of learning and improvement. 

More about MOREEX

On November 14-15, 2019, Dr. Ebert and Ms Osiowy hosted a meeting on the traditional territory of the Sylix in Kelowna. They brought together the Core Teams from the Interior Health RSON communities of Fernie, Creston, Revelstoke, Lillooet and Golden to learn about MOREEX from Salus Global representatives, Dr. Jim Ruiter and Lynn Popien. QNs and RSON community representatives, along with Interior Health Quality team members  Naomi Jensen (Manager, Quality Improvement & Patient Safety, IH – West ), Nail Helgason (Manager, Quality Improvement & Patient Safety), Nadine Jones (quality Improvement Consultant) and Scott Bowenn (Project Lead – Surgical Strategy), learned about the structure and function of the MOREEX framework and how to use its tools and supports in the pursuit of developing high functioning teams and enabling system change. 

Day 1 of the Kelowna session was spent highlighting the key principles of MOREEX and the elements critical to a robust patient safety environment which include:

  1. empowering people
  2. learning
  3. open communication
  4. patient safety as a priority
  5. teamwork
  6. valuing individuals

MOREEX is a patient safety and CQI program that leverages Interprofessional team-based training to develop expert teams. It establishes engagement and ownership of the process by empowering the people involved and supporting activities at the site incorporating contextual elements and focusing on local priorities that are meaningful for the providers and patients.  The work will be monitored via a dashboard utilizing culture assessment surveys, patient satisfaction surveys, impact evaluations and specific unit outcomes. 

The MOREEX program fits very nicely with the RSON CQI framework which focuses on six (6) validated constructs of highly effective team including:

  1. shared goal of patient centered care
  2. clear roles and expectations
  3. mutual trust
  4. effective and open communication
  5. measurable outcomes and timely feedback
  6. open, supportive, and visionary leadership

Interior Health explores MMSF, aka the Vincent Framework

The Measurement and Monitoring of Safety Framework (MMSF, aka Vincent Framework)

Parallel to the work of RSON, Interior Health recently engaged in a national project launched by the Canadian Patient Safety Institute called the Measuring and Monitoring Patient Safety Framework (MMSF, or the Vincent Framework as it’s known in the UK). This learning collaborative approach is delivered by expert faculty with mentoring provided over an 18 month period. During this Safety Improvement Project, participating teams are supported in rewiring their thinking on patient safety and work within their organization to foster and promote a new approach to safety. Naomi Jensen is championing this work, piloting the tool at Royal Inland Hospital in Kamloops where two surgical units have already implemented targeted activities. 

“MMSF links quality to safety and reminds us that monitoring our activity is just as important as measuring outcomes,” says Dr. Ebert. “MMSF provides a holistic lens to view safety at the patient, provider and system levels.”

Relationships and networks are foundational

Inherent in the conversation of quality and safety is the importance of relationships and networks. The opportunity for rural healthcare providers to meet together in Kelowna and share stories and learnings was powerful. All rural communities experience both shared and unique challenges and this was poignantly highlighted during the first day of the Kelowna meeting, when one of our communities suffered a tragedy. Administrative co-lead Karen Osiowy observed that the understanding, compassion, and support from the other group members reflected “how connected and devoted to our communities we are, and how important this work is, even when it’s difficult. We were all reminded of why we do what we do, and the event emphasized the importance of a supportive team. The innovation and creativity of our providers and their determination to serve their communities is inspiring.”


The Rural Surgical and Obstetrics Networks (RSON) is an initiative that seeks to stabilize, support, and enhance the delivery of quality healthcare to vulnerable rural BC rural populations, including Indigenous populations. It provides sustainable local/regional surgery programs “closer-to-home” in geographic areas served by Enhanced Surgical Skills Family Physicians (ESS FPs) or a solo General Surgeon through enhancing existing care networks shared with referral centres. Through this work, these rural surgical and obstetric networks support enhanced critical care, emergency, and trauma services while also supporting closer-to-home maternity care, including vaginal birth and Caesarian section.

The local/regional RSON model seeks to improve both patient and provider experiences of care by:

  • understanding holistic risk and cost associated with travel so mitigation strategies can be put in place;
  • supporting networks of high quality, highly effective maternity and surgical teams to provide the right care at the right time by the right providers
  • supporting rural providers to practice full-scope of rural generalist medicine
  • enhancing and supporting relationships between team members within the geographic network
  • providing a robust evaluative framework for quantitative and qualitative metrics applied to both maternity and surgical care
  • providing culturally and rurally appropriate care closer-to-home

RSON is an initiative supported by the Joint Standing Committee on Rural Issues (JSC) that is operationalized through the Rural Coordination Centre of BC working in collaboration with the health authorities, the Ministry of Health, UBC Rural Continuing Professional Development, and the Centre for Rural Health Research