Message from the Ontario’s Anesthesiologists’ Section Chair

It has been a year since the launch of our Choosing Wisely Implementation Guide (CWIG), a toolkit crafted to support anesthesiologists and enable them to demonstrate leadership skills within the perioperative suite, while helping elevate efficiencies in patient care. We are extremely proud of all the hospitals, peri-operative teams and anesthesiologists across Ontario who have stepped forward to demonstrate their commitment to patient focused care and health system improvement – and we trust that you have found the CWIG helpful support in this regard.

I am also delighted to share that we have received positive feedback about the CWIG from both physicians and Section stakeholders.  Members of the Beyond the Mask (BTM) Working Group and the Executive have shared the document at important meetings and conferences, including at the OMA’s bi-annual council meeting. Over 250 hard copies have been distributed to anesthesiologists and surgical colleagues. More recently, we shared the guide with national and international anesthesiologists at the CAS conference in Montreal. Feedback received indicate its relevance for other Canadian provinces, as well as for perioperative teams in countries such as Australia, Belgium, Taiwan, and France.

Screen Shot 2018-07-13 at 10.13.17 AM.png

We continue to acknowledge that none of this would have been possible without the heavy lifting by the Canadian Anesthesiologists’ Society (CAS) and Choosing Wisely Canada’s (CWC) whose initial hard work led to the development of these important recommendations.

So - one year later, where are we? Implementation efforts at the initial five sites continue.  Supplementing those are two smaller case studies that have been developed to bring new perspectives to the implementation process. Rounding out the Newsletter content are observations from Health Quality Ontario based on the Hospital Performance Series Reports, as well as an update from CWC.

The Canadian Anesthesiologists’ Society and Choosing Wisely Recommendations - 5 Things Patients and Physicians Should Question Last updated: June 2017 (Source:

We encourage our Members to support positive system change on an ongoing basis. Your Section Executive is continuing to champion new and transformative projects, so please feel free to reach out to them with suggestions or requests for support.  If you would like to hear more about our upcoming projects, participate in our BTM Working Group and/or share news of your local successes, please contact our Section Administrator, Emily Hill.   

Warm regards,

Dr. Christopher Harle, Ontario’s Anesthesiologists' Section Chair

New Implementation Stories

Our CW Implementation Guide, developed after the release of the CAS/CWC Recommendations, features five case-studies which were developed based on semi-structured interviews and data provided by each of the sites. To supplement these initial case studies, a sub-set of the initial questions was used to interview leaders from two additional sites. These interviews were conducted by the Section’s strategic consultant, Dr. Jane Cooke-Lauder, and administrative coordinator, Emily Hill. Included below is a synthesis of key information about each of these sites, together with brief commentary as to how these two case studies contribute to and/or extend Section 5 of the CWIG: Lessons Learned and Experiences Shared. Please click on the adjacent links to access the more detailed case studies.

Niagara Health System - Lessons Learned and Experiences Shared

  1. Multi-site system with a long tradition of a certain way of doing things. So making it as simple as possible to follow the new way was important. This included formal training and many informal conversations with surgical colleagues, creating ease of access to the new forms and instituting a three month transition period with a clear end date
  2. A telephone hotline was introduced to address patient inquiries and additional patient information brochures/newsletters were created targeting particular topics such as fasting requirements pre-surgery
  3. The importance of getting alignment across the full system: concern was expressed among the surgeons as to the attitude of players like CPSO to this change in particular and to changes in general that physicians were wanting to make to streamline patient care - but which might result in physicians incurring higher levels of risk.
Screen Shot 2018-07-19 at 10.36.46 AM.png

Niagara Health System

Norfolk General Hospital - Lessons Learned and Experiences Shared

  1. Used data from Hospital Performance Series Report to create the case for change
  2. Received support from the Perioperative Care Committee. Historically, perioperative decisions were the clear domain of the anesthetists
  3. Discussions were held and time was invested to bring the anesthetist group to being of one mind as to the need for this change
  4. Surgeons' questions and concerns were addressed immediately.
Screen Shot 2018-07-19 at 10.35.57 AM.png

Norfolk General Hospital

Interview with Health Quality Ontario

One of Health Quality Ontario’s strategic goals is to provide information back to providers to enable better decisions. Read more about the purpose of the HQO Hospital Performance Series, the next phase of reporting and ways Anesthesiologist can make a positive impact.... Click here for the full interview


A Message from Choosing Wisely Canada

Anesthesiologists in Ontario are helping to reduce inappropriate use of precious health care resources significantly while saving patients from potential harm,,” says Dr. Wendy Levinson, Chair of Choosing Wisely Canada. 

Choosing Wisely Canada (CWC) is delighted to recognize Ontario’s Anesthesiologists for their commitment to safe, efficient and effective care. This is in line with developments globally. The CWC’s "Drop the Pre-op" toolkit has been downloaded almost 3,000 times and has inspired similar efforts in numerous countries including the UK, Australia and the USA.  The development of the Choosing Wisely Implementation Guide by the Section, leveraging the Pre-Op toolkit, was a significant achievement and an important contribution to empowering grass-roots quality improvement. Now, one year later, we applaud the Section for taking the opportunity to reflect and share some new ideas and thinking around the CW initiative.

We would also like at this time to draw your attention to the recent announcement of multi-year research funding to Dr. Jeremy Grimshaw, in partnership with CWC and other national collaborators from the Canadian Institutes of Health Research (CIHR) Strategy for Patient-Oriented Research (SPOR) Innovative Clinical Trial Grant Competition. The project, titled ‘De-implementing low value care: a research program of the Choosing Wisely Canada Implementation Research Network’, will focus on two CWC recommendations, one of which is to reduce pre-operative testing in low risk ambulatory surgery. The project will be implemented in three provinces (Ontario, Alberta, and Newfoundland) and will comprise:

  1. Innovative cluster randomized trials (CRTs) of de-implementation strategies
  2. Building the conceptual basis and methods of implementation science; and
  3. Building capacity in innovative CRTs and implementation

The project, top ranked among all competition submissions in Canada, aims to reduce unnecessary pre-op testing significantly nationally by gaining better insights into the barriers and enablers that drive overuse and then providing pragmatic strategies for change.

We wish the Beyond the Mask project as well as all the members of the Section of Anesthesiology every good luck with the quest to reduce unnecessary testing in Ontario.

Dr. Wendy Levinson
Chair of Choosing Wisely Canada

Update from the Original Case Study Hospitals

The CW Implementation Guide includes five case studies from unique sites across Ontario, featuring the different approaches taken by each site to implementing the CAS-CWC recommendations. One year later, we followed up with the sites to inquire about their progress. Below are the responses from two sites, North York General Hospital and Trillium Health Partners. To access the original case study summaries in the CW Implementation Guide please click here.

Screen Shot 2018-09-06 at 12.53.27 PM.png
"North York General has been committed to ensuring the ongoing success of the Choosing Wisely approach in our Pre-Operative Assessment Clinic.  We have seen sustained success in reducing the number of unnecessary investigations for surgical patients by about 30-40%.  By promoting our positive changes internally within our institution, we have managed to create a culture-shift across anesthesiologists, surgeons and nurses.  Now, there is a strong sense that our collective default attitude is to question the need for patient investigations and limit ordering practices to those items that are shown to change clinical care or improve patient outcomes.  We have formed a hospital-wide Choosing Wisely Committee that meets regularly to ensure the sustainability of ongoing Choosing Wisely initiatives by reviewing concrete data generated from our institution's informatics department.  Maintaining multidisciplinary communication between physicians, nurses and administrators has created a work environment that has also allowed other hospital-wide Choosing Wisely programs to succeed."
Screen Shot 2018-09-06 at 12.53.32 PM.png
"The preoperative blood investigations grid has been applied to all patients receiving consultations in the preoperative anesthesia clinic. About 80-85% of patients follow the grid. The remaining  patients are receiving extra tests based on the surgeon's assessment of the patient. Overall, using the grid has resulted in a significant decrease in the number of unnecessary preoperative blood tests leading to financial savings.
The protocol for sickle cell screening in adults (> 16 years of age) has been updated. Currently, sickle cell testing is only done in high risk patients for sickle cell disease and/or patients who are possible candidates for using cell saver for blood conservation. These updates are diminishing the number of unnecessary testing for sickle cell disease including hemoglobin electrophoresis."

Choosing Wisely Implementation Guide

…. to support conversations and action to reduce unnecessary tests, treatments and procedures.

The Implementation Guide was developed to support anesthesiology departments in addressing all five Choosing Wisely recommendations, developed by the Canadian Anesthesiologists' Society, for reducing unnecessary pre-operative testing. Using a case study approach to reflect the diversity of the health system and a range of possible approaches, the Implementation Guide includes templates, tools, guidance and change management suggestions to enable all hospitals to benefit from reduced costs and improved patient care. This is achieved by not subjecting patients to unnecessary testing that requires them to visit the hospital more frequently and, more importantly, has the possibility of causing them harm.