91社区

How we set our goals, our plans and our metrics鈥�

Strategic planning exercises come in all shapes and sizes. Some strategic plans are developed by an individual leader (or small sets of leaders) and then delivered to a community/organization (i.e. top-down approach). We wanted our strategic plan to come from the ground-up, that is we want to hear the aspirations of our 91社区-wide Department of Medicine community and then develop a plan to deliver on those aspirations. We created a blank page and participatory exercise that focused on listening to all our members to hear their priorities (or aspirations) and their thoughts on how we might achieve these aspirations. Through a series of open-ended questionnaires, 10 ranking exercises and 10 town halls conducted over 8 months (Oct 2022-June 2023) with excellent representation across sites, career paths and equity seeking groups we ensured that all voices were invited, included, and represented in OUR Strategic Plan.

The Strategic Plan Exercise was divided into three phases:

1. Defining our Aspirations
2. Tools & Processes: How to Get There
3. Metrics: Defining how far we鈥檝e gotten to the destination

Phase I: Aspirations

We conducted open-ended surveys and townhalls asking our community members to provide at least one aspiration for our Department in the next five years. We received over 180 aspirations that we grouped into seven 鈥淎spirational Themes鈥濃��

• Effective advocates for the best patient care in resource constrained environments
• Planetary health
• Most research-intensive DOM in Canada
• Patient & community engagement
• I love working here!
• As diverse as those we serve
• Training centre of choice

After further Delphi ranking survey work, we whittled down to four Key Aspirational Themes:

We then surveyed the membership (again!) and identified the top three aspirations within each of the four Key Aspirational Themes, for a total of twelve aspirations. These are detailed below.

Phase II: Tools/Processes

Having identified where we want to go, we then held brainstorming town halls to identify the tools and processes needed to reach the twelve aspirations. This work will form the focus of our collective efforts over the next five years.

Phase III: Metrics

Finally, we identified one trackable 鈥済lobal鈥� metric for each of the twelve aspirations. These metrics will serve as our indicators along the journey, helping us determine whether we are making progress, following the correct course, or nearing the fulfillment of our aspirations.

Key Aspirational Theme: Training Center of Choice

Top three aspirations:

In order to establish the CORE Internal Medicine (IM) program of choice in Canada, it is crucial that our program stand out as the best training program in the country. We will accomplish this by ensuring that our curriculum is cutting edge and at the forefront of advancements, equipping our IM trainees to navigate expected developments in the practice of Internal Medicine (e.g. digital innovations including artificial intelligence). Consequently, we will attract and recruit clinician teacher/educators in the areas of 1) point-of-care ultrasound (POCUS) and 2) simulation. These recruits will develop and deliver high quality effective training in 1) POCUS and 2) a robust simulation program focussed on high stakes scenarios (critical care simulation, procedure training, professionalism simulation, inter-professional communication, crisis resource management, evaluating/being evaluated, assertiveness training and other areas of current/future need). Our leadership will ensure that the necessary time and resources are incorporated in our CORE IM training program to accommodate these innovative programs.

We will develop a CORE IM dual path clinical/research training stream. This will offer our CORE IM residents who aspire to become clinician scientists a strategic advantage, enabling them to expedite their journey towards becoming fully trained clinician scientist (detailed below).

We will attract the best candidates to our CORE IM program by bolstering the quality and accessibility of of medical student electives to both 91社区 and non-91社区 students. We will capitalise on the unique bilingual and multi-cultural nature of Montr茅al and 91社区 to attract top candidates from Qu茅bec universities and from across Canada. We will thereby enrich our pool of future 91社区 recruits who have chosen to learn French and make Montr茅al/Quebec home after their training. To support trainees we will equip our residents with resources to enhance their language skills such as on- site language tutors, language buddies (i.e., pair a francophone trainee with an anglophone trainee to text, teach, and practice each other鈥檚 languages), provide better access to a dual language medical abbreviation handbooks and supported duo lingo subscriptions.

Metric: CARMS data: Composite rank of all who matched to our program (i.e. specifically how deep we went in our list to rank resident accepted in the program (higher rank=better)

We highly value creating a healthy and safe learning environment for ALL trainees. When clinical service demands are higher, there is less time and space to thrive personally and professionally. As patient care demands grow in the next 5-10 years driven by an aging population with greater medical complexities, it becomes imperative to forge new routes and locations for care and to 鈥渞ight size 鈥渙ur clinical teaching units (CTUs) (20-24 patients) . The current model of trainees overseeing all hospitalized patients is no longer tenable. We will work to increase our physician numbers (specialist PEMs, hospitalists) and physician extenders (nurse practitioners, physician assistants, scribes) via MSSS/hospital level advocacy and our own internal initiatives. These physician/physician-extenders will help staff non-teaching units, day hospitals, and rapid access clinics. We will collect and analyze data based on audit and feedback and continuous 鈥渆ducation quality improvement loops鈥� to ensure our CTUs deliver optimal learning, teaching, and patient care environments. We will drive culture change towards an 鈥渆ducation through service鈥� mindset to reset/align expectations with the reality of modern IM practice. We will develop and implement annual Faculty level learning environment simulations on giving feedback, avoiding micro-aggressions, coping with multiple simultaneous demands and other high-stakes scenarios.

Metric: Annual survey of all DOM trainees to (target 80% response rate) asking Q: 鈥淚n the last year, I felt harmed or unsafe in a 91社区 DOM learning environment鈥� A: never, once with some impact, once with serious/important impact, multiple times with some impact and multiple times with serious/important impact

Clinician teachers are the lifeblood and face of an academic medical department. We want our clinician teachers to feel valued through recognition for stand-out contributions. We will implement better systems to accurately track teaching contributions (quantity and quality). Specifically, we will increase teaching awards with at least one UGME award per site and at least one teaching award per residency program per site. We will create an Annual DOM Clinician-Teacher symposium to showcase the tips/tricks of our stellar clinician-teachers and bring-in leading external education/teacher speakers. We will measure/report/feedback teaching excellence at the individual Faculty level, Division and DOM aggregate levels (e.g. DOM wide overall One45 rating). We will ensure this feedback is high quality by providing student/resident training on providing meaningful and actionable Faculty feedback. We will rigorously pursue high Faculty evaluation completion rates to ensure representative sampling. We will continue to review these evaluations 1:1 at Faculty Annual Reviews. On the flip side, we will measure/report and feedback EPA/CAF/ITER completion rates at individual Faculty level to ensure timely and complete trainee feedback- we will celebrate our 鈥渃ompleters鈥� and explore barriers to completion for 鈥渘on-completers鈥�. We will advocate for IT solutions to facilitate complete and accurate collection of this data.

Metric: Annual survey of 91社区 DOM Clinician Teachers (self-identified through Annual Evaluation) Q: My contributions as a teacher are valued by my Department/Division/Colleagues/Trainees A: not at all, somewhat, adequately, quite a bit, a lot.

Key Aspirational Theme: Most Research-Intensive DOM in Canada

Top three aspirations:

We will bolster our clinician scientist (CS) numbers through a bigger/better clinician scientist career path pipeline by 1) enhancing medical student research elective/summer student opportunities (CS career path 鈥渢asters鈥�) and 2) Dual path residency/fellowships: we will permit/encourage MSc/PhD research electives/clinical training breaks/leaves during residency (CORE through to sub-specialty to fellowship) to allow 3-12 month blocks to complete MSc/PhD courses/thesis work in order to shorten total duration of physician scientist training (i.e., maximize overlapping Royal College permitted research months in clinical training programs to permit simultaneous MSc/PhD program progress). We will synergize with and take better advantage of the Clinical Investigator Program to increase the number of MD MSc and MD PhD scientists in our CORE and sub-specialty training programs.

We will revamp our Graduate Program (change 鈥淒ivision of Experimental Medicine鈥� to 鈥淕raduate Program in Clinical and Translational Research (with MSc/PhD in 1) Experimental Medicine, 2) Digital Innovation and 3) Clinical Research) to complement our dual path efforts. We will optimize the use/success of FRQS 鈥淔ormation de recherche pour les r茅sidents鈥� and 鈥渇ormation en recherche post-dipl么me professionnel鈥� programs to support residency research and post-residency research training.

3) Grow research fellowships (post-RCPSC training) to not only attract clinicians pursuing research training at 91社区 but help fund our most promising 91社区 trainees to complete external research training in anticipation of a return to 91社区 in our world class teams. We will develop dual path funding support programs with internal resources (e.g., DOM practice plans) and efforts with our Foundations, to complement and build on funding available through FRQS and CIHR.

4) We will continue our highly successful early career Faculty CAS research program as a bridge to FRQS J1 funding and 5) Keep/strengthen/advertise the post-FRQS senior 鈥渢enure for clinicians鈥� program to ensure our brightest mid-career scientists stay and grow after they have completed the FRQS Senior/RAMQ 鈥淩emuneration Recherche鈥� (REM recherche) programs, whereby ongoing support, post- FRQS Senior, is provided by the University. We will advocate that the salary support grows from the current $120,000 per year to $150,000 per year (adjusted for inflation over the next 5 years) to better approach the expected 50% protected time and specialist clinical earnings i.e. adequately support 50% protected time now and in the future.

Metric: Number of DOM Faculty who identify as Clinician Scientists at the Annual Review exercise (verification steps to include: on FRQS, those clearly identified as "pre-FRQS" via DoM support program, or FRQS Senior graduates who continue to hold competitive, peer-reviewed external funding i.e. CIHR, NIH, Heart & Stroke etc) and measure DOM wide cumulative publications in a shortlist of top general medical/life sciences journals plus 2-3 top journals in each DOM subspecialty.

We will ensure PhD scientists and clinicians co-create to develop the most translational DOM in Canada through 1) bolstering PhD recruitment through CAS research funding opportunities for PhD Scientists in targeted priority areas with competitive future tenure track positions in our priority areas, 2) Continue aligning PhD Scientists with Clinical Divisions to maximize multidisciplinary collaboration; involvement of clinical leadership (Division Directors) as well as leaders of our research institutes in setting direction and leading searches, 3) create a 鈥渢ranslational grant鈥� funding opportunity to bolster new collaborations between DOM PhD scientists and DOM Clinician Scientists/Investigators, rewarding those most likely to be sustainable and most likely to deliver external funding success and 4) Divisional and MGRs 鈥淭ranslational Rounds鈥� with co-presenters (PhD and MD) presenting translational work (planned or completed) and/or the science and clinical aspects of a disease entity/test/treatment.

Metric: Publications that combine a first/senior author DOM Clinician Scientist with a DOM PhD scientist (or a first/senior author DOM PhD scientist with a DOM Clinician Scientist).

More world-class research teams than any other DOM in Canada (i.e. teams of multi-disciplinary scientists working in a specific 鈥渁rea鈥� of focus). We will start with a q 4 yearly DOM process to identify our top three world class teams and three emerging world class teams across the 91社区 DOM ecosystem. This will be achieved through an open, transparent competition with written submissions and presentations by self-identified groups working in an 鈥渁rea鈥� led by 91社区 DOM members. They will articulate the structure (who), function (how), funding (with what), recent and future outputs and describe world comparable teams of their 鈥渨orld class team鈥� in 鈥渁rea X鈥�. Priority will then be given to our identified /emerging world class teams in all areas under the DOM鈥檚 direct control (fellowships, CAS funding, recruitment) and in areas where DOM鈥檚 advocacy is essential (e.g RI and Foundations).

Metric: Number of programs in DOM where two or more DOM scientists are in top 100 in a cadre of global reputation indices (Expertscape and Research.com).

Key Aspirational Theme: I Love Working Here

Top three aspirations:

Academic medical environments are complex. We work in multiple institutions and wear many hats including health care provider, teacher, scientist/investigator, leader, and many own/operate individual/group businesses. All our Faculty wear at least two hats and some all these hats (and more!). We can get lost as people assuming all these roles and the resultant pressure cooker of multiple competing demands. We commit that our leaders and our colleagues will advocate for our institutions to care about our members as people. Our community told us it was important to gather in common spaces like Faculty lounges, hold regular social events in these spaces, hold Annual DOM wellness retreats that combine activities with wellness lectures and to continue Schwarz Rounds to share/discuss the difficult hot button issues we face. Our DOM Mentorship program has been a success and will be expanded with more mentees/more mentors and better trained mentors. We will consider developing a 鈥淏uddy鈥� system to ensure each of us has a colleague we can lean on. We will continue our leadership development efforts to ensure our leaders (and their successors) are wellness role models and effective at creating healthy individual, teams and workplaces. We will explore coaching programs to supplement our leadership development efforts and to help our Faculty members in difficulty.

Metric: Annual wellness survey with elements to include a professional fulfilment index and burnout scale.

A digital transformation/revolution has started in healthcare and academia and will accelerate in the coming years. We want to ensure that our 91社区 ecosystem is a place where digital and other innovations lead to top notch provider experience and administrative excellence. We will advocate for a single provincial EMR (and at a minimum a single EMR at 91社区 affiliates). We all value the efficiencies and improvements in care brought by fully integrated system wide EMRs but we are leery of EMR driven burnout. We will ensure that good EMR 鈥渉ygiene鈥� includes screen breaks, a 鈥渞ight to disconnect鈥� and provider friendly work flows and tools (e.g. integrated high-fidelity dictation). In our academic lives, we also want digital tools that facilitate trainee evaluations, annual review, COI declarations, mandatory training (e.g. research ethics, GCP, 鈥淚t takes all of us鈥�) and minimize the administrative burden with being 91社区 Faculty members.

Metric: Annual survey Q: We did it! Digital innovations have made my hospital work easier A: No (it鈥檚 worse), nothing has changed, a bit better, better, much better; Q: Digital innovations have made my academic work easier A: No (it鈥檚 worse), nothing has changed, a bit better, better, much better

In academia and in medicine, we work in teams. We recognize the benefit to our patients, trainees and science by helping those who work with us to grow. It starts with our leaders- we will continue to invest in leadership development for our Division Directors, Program Directors and other leaders (and their successors). We will focus on large group (e.g. DOM Soiree) and small group team building sessions/exercises to build on our sense of community and that our staff are members of that community. We will work with the administrative leaders of those on our teams (AEC 8 Director and AEC leaders, Nursing and other leaders) to ensure that we are partners in helping members of our teams grow (e.g. providing space/time, patience and resources for team member development, constructive feedback for their performance reviews, support mentorship programs). We will ensure our Faculty are always respectful/professional and have reasonable expectations of our team members.

Metric: Annual All-DOM survey (staff, trainees, Faculty) Q: I love working here! A. Not really, at times, most of the time, yes, absolutely!)

Key Aspirational Theme: Effective Advocates for Patient Care in a Resource Constrained Environment

Top three aspirations:

Delivering/developing digital innovations that improve access to quality care (state of the art EMRs, patient-facing apps, virtual care). The importance of digital innovation and transformation is woven through many of our aspirations, including our desire to deliver excellent high-value patient-centered care. While the DOM can鈥檛 buy a province wide EMR, we can educate the public and advocate at decision making levels that these tools are as critical as the bricks and mortar that form our hospitals. An EMR isn鈥檛 enough. We need enterprise hospital management systems that render our clinical practice environment safe and efficient (e.g. electronic medical order entry, end-to-end barcode verified medication dispensing, administration and reconciliation), Apps that track patient attendant beneficiary requests (like an Uber you know where they are/when they will arrive), end-to-end electronic menu choice and meal delivery (like Uber Eats in a hospital), micro-costing to allow us to intervene/deliver high-value care as we transition to 鈥渇inancement ax茅 sur le patient鈥� (patient based or bundled care financing), end-to-end test/imaging management (i.e. results viewer and a system for requisition visibility to manage a predictable waitlist for tracking/acknowledgement of requested tests and imaging), patient safety alerts, rapid access to data and analytics, and pragmatic RCT infrastructure to create a learning health environment.

Patients have a right to their data and quick easy access to their expected care path/journey. We will advocate for digital solutions that include ability to use Apps/integrated software solutions to schedule appointments, receive appointment reminders, confirm appointments, self check-in, wait where they want, be electronically called in to a room, etc. We will advocate for these solutions to include patient specific education materials as patient self-care grows in importance. These materials, Apps, and software solutions will be decolonized and indigenized, to better serve our indigenous populations. Patient self-care will be enhanced through digital/AI developments that may indeed replace some of the care we currently deliver face-to-face in our bricks/mortar (e.g., self- triage tools, drug self-dosing and other self- management tools). We will deliver virtual care platforms to position us for the future and provide access to our expertise for those who live in remote communities. We will continue to grow and advocate for cutting edge virtual care initiatives such as hospital at home programs, e-consultations (GP to Specialist 鈥渜uick question鈥� consults) and tele-health for the right patient/right problem/right time/right tool. All the above require physician champions and experts with protected time to advocate, deliver, and help us design, test, and implement digital innovations. We will target digital innovation recruits and protect their time. We will strengthen our leadership in Digital Innovation through targeted recruitment, through bolstering our MSc and proposed PhD in Digital Innovation, and position ourselves to be leaders in this space. While we have little direct control over hospital environment decisions, the Glen Center for Specialised Medicine and our Innovation Hub neighbours provide opportunities for DOM (not just MUHC DOM) to develop/research/deliver many of these solutions in our own not-for-profit out of hospital ambulatory care setting.

Metric: Digital solutions scorecard: Q: Do we have a provincial EMR A. Yes/No; Q: Do our major teaching hospitals have an enterprise hospital management system? A. Yes/No; Q. Do our major teaching hospitals have MyCharts (or similar) A. Yes/No; Do our major teaching hospitals have a patient facing app? A. Yes/No; Do our major teaching hospitals have robust virtual care services? A. Yes/No

Contributing and advocating for solving the current/coming human resource crisis. We are keenly aware that our governments have not planned for the demographic/multi-morbidity bubble we face in the next 5-10 years and quite the opposite, delivered poorly timed reductions 5-10 years ago in our medical/nursing/allied heath/technician training programs. We will bolster our advocacy efforts to accelerate training of health care professionals (and extenders) to match our actual needs to avert the impending crisis. We are not trained to advocate but we will recognize/value advocacy by our trainees/Faculty and improve their advocacy skills through dedicated advocacy training workshops. As above, we will also work on physician extender programs (NPs, physician assistants, and scribes) to mitigate the effects of the crisis on our trainees/Faculty.

Metric: Number of DOM member led advocacy campaigns per year focused on quality-of-care initiatives including solving the consequences of the health human resources crisis

Rendering state of the art diagnostics and therapeutics accessible to all Quebecers. We will conduct annual surveys of our physicians to identify 鈥渢herapeutic and diagnostic鈥� access gaps. We will choose priority gaps, identify an advocacy champion, and support their advocacy campaigns.

Metric: Number of DOM member led advocacy campaigns per year focused on quality-of-care initiatives including fixing therapeutic and diagnostic access gaps.

Values: Throughout the process we heard important, entrenched and well supported values that characterise 91社区 DOM today and will only be strengthened tomorrow: Diversity/Inclusivity/Accessibility, Excellence, Patient Partnership/Community Outreach, Collaboration, Sustainability, Transparency and Wellness. We want to ensure that we are as diverse as those we serve and that our patients/communities have a dominant voice in the care we deliver and research we conduct. We recognize that planetary health is intimately tied to human health. We are keenly aware that we can鈥檛 help look after others if we don鈥檛 look after our own health and wellness. Finally, 91社区 has a long tradition of excellence and while we celebrate/honor this long history, we will continue to strive to make history.

Conclusion: It is challenging to sum up in a few lines nine months worth of deliberations. However, if we are successful in our efforts in the next five years we will have achieved our goals of鈥� 鈥�Transforming care locally through effective advocacy, digital innovation and attracting/training the best and brightest. Transforming care globally through world class translational research teams. Providing a safe and healthy learning/work environment where we value your growth.鈥�