Completed Medical Staff-led Projects

Medical Staff-led Engagement Projects

Completed projects funded through PHC PASS Facility Engagement are listed below, grouped by their primary strategic priority.

For information on the 2024 Pillar-focused Engagement Project intake, visit our Funding webpage.

From 2017 to 2022, approximately 60 individual medical staff-led projects have been funded by PASS, through the Facility Engagement program. Each project has been aligned with one of our strategic priorities. This has included special intakes for COVID-related projects in 2020 and vision-supporting projects for the New St. Paul's Hospital in early 2021.

For questions or to connect with project leads regarding their projects listed below, contact

Exceptional Quality, Safety & Value

Learn more about the EQSV Pillar here.

Completed Projects:


The Baby-Friendly Initiative – Dr. Valerie Rychel
SPH was selected as one of 25 hospitals in Canada to join the Baby Friendly Initiative (BFI) National Quality Collaborative, and has set a goal to achieve Baby Friendly designation by June 2021. This project intends to facilitate the required multidisciplinary involvement to complete this national project.


Department of Medicine Working Group for Physician ProposalsDr. Andrew Ignaszewski
The Department has struck a working group to review, evaluate and / or mentor the top priority proposals submitted by its Divisions. This mechanism will support physicians in the further business development of selected proposals, and enhancing the physician voice in submitting these proposals for SLT consideration. Highlighted proposals demonstrate opportunities for transformation and innovation, and the promotion of interdivisional and interdepartmental collaboration while remaining patient-centred and aligning with PHC’s values and strategic priorities.

Improving clinician engagement with Advance Care Planning using the Serious Illness Conversation GuideDr. Ruth MacRedmond
The overarching aim of the project is to continue to train all of the physicians at SPH in the use of the Serious Illness Conversation guide and to support them in adapting it to their practice, in an effort to improve our system of recording patient preferences for advanced care planning, taking into account patient preferences for care, along with their goals, fears and values. This aligns with PHC’s 2015 commitment to a culture change in advance care planning in our organization, reflecting our commitment to patient-centered care through shared decision making.

Improving ED physician confidence in hand-washing statisticsDr. David Agulnik
One of seven COVID-19 projects funded through one-time extraordinary contingency funding. The project aims to improve hand-washing compliance by physicians in the ER, through improved communication and a parallel validation of internal audits by ER physicians.

Reduction of Diagnostic Waste in Anatomical Pathology – Dr. Nickolas Myles
A project to isolate and reduce diagnostic waste in anatomical pathology as a step towards reduction of wasteful laboratory investigations.

Nurturing Physician Leaders Through Value-Based Health Care (VBHC) at PHC – Dr. Shannon Jackson
The original intent of this project centered around the development of leadership skills amongst physicians. Early engagement surveys revealed that physicians had a strong interest in the topic of Value-Based Health Care, and the project pivoted to become two separate workshops: “Value-Based Health Care 101” in November 2020 and “Value-Based Health Care 102” in February 2021, delivered by Dr. Jackson. These workshops stimulated widespread interest across PHC, and VBHC is fast becoming a critical guiding principle of PHC strategy and clinical practice.


COVID-19 SimulationsDr. Shannon Lockhart
One of four COVID-19 simulation projects funded through one-time extraordinary contingency funding. Project leadership guided over 300 physicians, nurses, RT’s and AA’s in simulated PPE and airway management modifications for COVID suspect or diagnosed patients. Outcomes included demonstrating the importance of checklists and spotters, importance of system implications (ward, ED, ICU, OR) of changes in protocols, need for frequent communication amongst stakeholders, and identifying and mitigating challenges with doffing of PPE.

Inspiring People & Teams (Formerly Physician Community and Wellness)

Learn more about the IPT Pillar here.

Completed Projects:


Emergency Staff High Performance Team Building – Dr. Jeff Coleman & Dr. Erin Kennedy
A project to engage more closely with SPH ED physicians, nursing, administration and allied health professionals in identifying and implementing opportunities for improved communication, team dynamics, professional satisfaction and quality patient care.

Improving Access to Medical Services from Holy Family RehabDr. Evan Kwong
A project leveraging Cerner and Virtual Care to improve the efficiency of care of rehab patients who, due to the complex nature of their co-morbidities and recovery from acute medical issues, may have other more urgent medical needs as well. This may both decrease the need for transporting inpatients away from Holy Family Hospital (cost-saving), and allow an opportunity to test whether virtual appointments with specialists may be enhanced by the presence of HFH nursing, allied health or site physician as needed.

(On hold due to COVID-19) MSJ Gathering: The Scrub Glub Club V. 2- Dr. Fred Rydz/Andrea Tothill/ Fern Reilly
A series of social engagement events at MSJ where groups of physicians can interact socially and better understand each others’ needs and skills.

(On hold due to COVID-19) Social Noon Rounds v. 3 Dr. Tony Wan
A project to improve physician engagement and shared understanding between physicians about patients’ care concerns or about other topics of interest in the form of a noon social drop-in.


Fostering a Culture of Communication and Collaboration through Ultrasound Peer Training Program – Dr. Su-Yin MacDonell
A collaborative project within the anesthesia department to create a culture of learning, by increasing the skill set as a group to identify and diagnose an unwell patient faster. Helping colleagues identify specific expertise within the radiology (ultrasound) department.

PPE, Airway and Resuscitation Support – Dr. Chris Schneck / Dr. Emilia Rydz
One of four COVID-19 simulation projects funded through one-time extraordinary contingency funding. The project team standardized use of PPE in resuscitation at MSJ ER and on Code Blue events on the ward for ER doctors.  This included teaching and reinforcing best practices during AGMP events and regular patient care in the ER.

Social Noon-Rounds (v2) – Dr. Tony Wan
A project to improve physician engagement and shared understanding between physicians about patients’ care concerns or about other topics of interest through a noon social drop-in. Click here for final report.

Youth Mental Health Projects ReviewDr. Daniel Lin
An event to engage staff psychiatrists in a review of outstanding issues around Youth Mental Health Programming, with the goal of reviewing: process documentation for substance use management at Renfrew House; a decision around current capacity for additional Stream of care if possible; and ethical discussion around stabilization on care.


Breakfast in Res Care – Dr. Nardia Strydom
A project to facilitate physicians meeting in each others’ work environments for breakfast and a tour (starting in a residential care facility), to gain insights and share information about patients. Click here for final report.

Development of new 7-year strategic plan for Providence Health Care –  Josephine Jung / Dr. Jeff Pike
A project initiating the development of new 7-year Strategic Plan for PHC through a physician engagement strategy-led design. This project involves 4 selected physicians within 7 months. Click here for final report.

Learning from Every Death Initiative – Dr. Nardia Strydom
Training for 5 to 20 physicians to conduct mortality reviews in a structured format at a monthly team meeting that crosses departments and disciplines. Click here for final report.

Mindfulness-Based Stress Reduction for PHC Physicians – Dr. Jani Laramée
A project for PHC physicians to gain knowledge and learn new skills in mindfulness techniques, to learn how to better manage perceived stress, to improve a sense of empathy, ultimately to improve physician wellness and decrease burnout. Click here for complete final report.

MSJ Second Wednesdays Gathering: The Scrub Glub Club – Dr. Nora Cummins
A series of social engagement events at MSJ where groups of physicians can interact socially and better understand each others’ needs and skills. Click here for complete final report.

SPH Family Practice teaching service Engagement and Redevelopment – Dr. Pierre-Paul Lizotte
A project to develop a new model of care and education in hospital for a new revamped Family Practice Teaching Service. Click here for final report.

Sprout Wellness – Dr. Darra Murphy
A project to develop a user-friendly online platform called Sprout (, to provide opportunities for medical staff to join colleagues in fitness and community activities to improve physician health and connections. Click here for final report.

Staying Human(e): Keeping Compassion in Emergency Medicine – Dr. Andrew Kestler
A one-hour workshop with guest speaker Dr. Laura Kelly addressing topics of Stress, Burnout and Resilience; Psychological and Social Distress; Roots of Addiction; and Coping Strategies for physicians and patients.


A Day in May: Learning from Music and Coaching to Optimize Psychological Readiness in Surgical Care – Dr. Brian Westerberg and Dr. Jane Lea
A one-day symposium for surgical team members to optimize personal psychological readiness, and function at peak capacity using examples in from music. Click here for final report.

Coffee on Weekends – Dr. Chris Schneck
A project to support ER physicians and staff by bringing coffee into the ER at Mount Saint Joseph’s on weekends, so they do not need to leave the hospital to get coffee when the cafeteria is closed on weekends. Click here for final report

Internal Medicine Social Noon-Rounds – Dr. Tony Wan
Regular opportunities during a monthly lunch gathering for physicians to learn about their colleagues’ work outside of patient care, and share their research project progress, ideas or interests. Click here for final report

New Physician ‘Welcome Wagon’ – Dr. Janet Simons
A project to welcome new medical staff to PHC by having mid/late career PHC physicians meet with new staff in a social setting to provide information, and foster connections and collaboration. Dr. Simons held an event in late 2018 to welcome new staff to PHC.

Respiratory Division Retreat: A One-day Strategic Planning Session – Dr. Chris Ryerson
An avenue for all division members at SPH and VGH to renew its strategic vision and mission, and create a strategic plan for its future operations.Click here for final report.

Yoga for PHC Physicians – Dr. Jani Laramée
A project offering PHC physicians fully-funded weekly yoga group classes for 12 weeks by a certified instructor, to enhance wellness and build a sense of community. Click here for final report.


A retreat to enhance Communication Amongst Emergency Physicians and Between Emergency Doctors and Consultants – Dr. Rob Stenstrom
A 2- to 3-day retreat away from the hospital for radiology, cardiology, internal medicine, general surgery, and orthopedic surgery was held in 2018. Brief final report of this retreat is here.

Discover, Learn, & Innovate for Impact (Formerly Innovation and Modernizing IT)

Learn more about the DLII Pillar here.

Completed Projects:


Connecting the Dots: Improving Health Service Delivery for Individuals with a Substance Use Disorder at St. Paul’s Hospital Though Interdisciplinary Collaboration– Dr. Seonaid Nolan
A project to bring together key service providers within SPH through in-person meetings, to contribute feedback regarding the current system of care for patients with a substance use disorder at SPH and identify opportunities for improvement.


COVID-19 PPE Simulations Project – Dr. Jeanne Macleod
One of four COVID-19 simulation projects funded through one-time extraordinary contingency funding. This project will develop educational resources (instructional videos), and real time simulation to prepare ED physicians for the second wave of the COVID 19 pandemic, with a focus on when ED physicians need to don PPE for an intubation in the ED.

Establish a virtual/COVID-safe model for all multidisciplinary clinical rounds at PHC – Dr. Wei Xiong & Dr. Lik Hang Lee
One of seven COVID-19 projects funded through one-time extraordinary contingency funding. Involves setting up a virtual model of multidisciplinary clinical rounds (MDCs) that will function during social distancing periods, to allow for improved rounds implementation for off-site attendees or with members from multiple institutions even during non-COVID times (thus reducing travel times), and for rounds to continue uninterrupted in the event of a second or subsequent wave of COVID that is expected to occur.

Integrated Online Patient Pathway Portal for Complex Pain Patients – Dr. Jill Osborn
A project implementing an integrated online patient pathway of Pain Clinics at SPH that is accessible by physicians and allied health care professionals (AHPs).

Pathology Grossing Camera and Communication SystemDr. Lik Hang Lee
A collaborative project to spearhead the creation of a system of real-time communication with surgeons, technologists, and pathology assistants remotely (especially at MSJ) to correctly gross pathology specimens, understand the areas of clinical importance, document the gross pathology, and correctly choose tissue for research purposes, through the development of a pathology gross camera system with remote operations. The intention is to improve patient outcomes by improving the accuracy of communication, currently achieved only by description over the phone with no visual.

PHC Integrated Clinical Care Post-COVID Clinic – Dr. Nardia Strydom, Dr. Jane McKay, Dr. Adeera Levin
One of seven COVID-19 projects funded through one-time extraordinary contingency funding. The goal was to guide the set-up of a post-COVID clinic at PHC that aligned its practices and protocols with the PHSA-led initiative to establish standardized post-COVID care across BC. Jointly funded by Shared Care.

Surgical Coaching ProgramDr. Jane Lea
A project to pilot a surgical coaching program at PHC that fosters a culture of lifelong learning and self-reflection among experienced practicing surgeons, while promoting and supporting the use of personalized coaching as a tool to facilitate this. The intention is to demonstrate the first model of its kind in Canada, and encourage national adoption of such a program here.

Transforming MRI Scheduling: Optimization for Clerical Staff & Radiologist – Putting Patients First – Dr. Darra Murphy
A project to create a smart system that intercepts the requisitions coming in from central intake and triages them into broad categories.


COVID-19 Resuscitation, Airway and PPE Preparation – Dr. Jeff Yoo
One of four COVID-19 simulation projects funded through one-time extraordinary contingency funding. Dr. Yoo’s team implemented changes in intubation, PPE, and equipment preparation to mitigate the risk of COVID-19 disease transmission to health care providers during intubation. Click here for final report.

How to Engage Physicians and Health Care Providers in the Treatment of Patients with Fragility Fracture- Dr. Sabrina Gill
A project to optimize the recognition of patients who present with fragility fractures presenting to physicians at St. Paul’s Hospital and to develop an effective and efficient process to optimize assessment and treatment of osteoporosis and to develop an awareness of the role of a fracture liaison service. Click here for final report. 

Innovation, Collaboration & Creating Partnership: A Proposal – Dr. Alan Rabinowitz
A project creating discrete networks of primary care providers linked with a formal network of specialists from PHC. One of the main deliverables is to implement a shared charter complete with relationship-building activities.

Multidisciplinary Team Engagement – Dr. Jeanne Macleod
A project to develop a sustainable Simulation Program, to promote team building, encourage multidisciplinary learning, improve patient care, and foster better relationships between departments.

Telling the Story of PHC’s Involvement with the Supercluster Dr. Amin Sajan/ Mr. Justin Karasick
The project developed a series of videos, one for each of the four SuperCluster projects (one video is pending). The purpose is to build momentum and excitement around PHC’s role in the Supercluster, and demonstrate how medical staff are contributing to the development and achievement of plans and innovation initiatives that directly affect physicians. Videos will be shared widely with multiple internal and external audiences via PHC’s communications strategy.

State of the Art Teaching and Learning Through Simulation at SPH – Dr. Jeanne Macleod
A project to establish a simulation committee with representatives from different departments and governance structure, intended to enable physicians’ groups who wish to develop simulation programs to get together and collaborate and create a culture of learning and innovation at SPH.

SPH 10C Multidisciplinary Case Rounds Pilot – Dr. William Connors
A project reviewing historical and educational cases in the Urban Health Infection Unit at SPH (UHIU-SPH/10C) to obtain clarification of patient care plans and in the long run to build a framework of the ideal multidisciplinary rounds.

Utilization Dashboards Proof of Concept – Dr. Dan Holmes & Dr. Janet Simons
Rapid access to hospital testing utilization data is hampered by slow connections to SQL databases, slow queries (hours), latency in loading data onto desktop computers for analysis, and potential privacy concerns. This project successfully showed how these problems might be overcome by creating a dashboard tool that runs real-time rapid queries through a distributed computing solution with the Apache Spark platform.


Data Science for Doctors – Dr. Dan Holmes and Dr. Janet Simons
A project introducing physicians to basic data handling and visualization, and providing tools to facilitate reproducible research using the R statistical programming language. Click here for final report.

Data Science for Doctors, February 1st – 2nd 2019, at Doctors of BC.

Decreasing departmental costs through price awareness – Dr. David Agulnik
A project engaging hospital administration to make the true cost of the disposable supplies/products on a per-use basis visible to hospital staff, to create less waste and/or find lower cost alternatives. Click here for final report.

Development of a high-fidelity mannequin for E-CPR (ECMO-facilitated CPR) simulations – Dr. David Agulnik
A project to modify a CPR mannequin to enable high fidelity simulations for a cutting-edge complex procedure in which ER physicians and surgeons perform ultrasound guided cannulation of both femoral vessels while CPR is being done. Click here for final report.

Enhancing the Continuum of Stroke Patient Care – PHC – Dr. Evan Kwong
A project facilitating interaction and engagement between front-line physicians who are involved in the care of stroke patients at PHC, and with PHC and VCH, around the efficiency, timeliness, and complexity of patient-centered stroke care, rehabilitation, and complex discharge needs. Click here for final report.

Enhancing Quality of Life in Long Term Care – Dr. Ken Tekano & Dr. Marcus Greatheart
A Distinguished Speaker dinner event entitled “Rethinking Autonomy, Risk and Human Rights: A Relational Approach” with speaker Dr. Al Power. This was a discussion to reflect on improving quality of life and care practices for dementia patients, who face restricted participation in decision-making when in long term care. Around 60 participants attended from Dept of Family Medicine, Div of Residential Care, Emergency Medicine, and Social Work.​

Cerner/CST – Conversations that Matter to Physicians – Dr. Victor Leung
A project engaging physicians from three Health Authorities (VCH, PHSA, and PHC) to understand how Cerner/CST will change the workplace. The main goal was to create a coordinated list of priorities shared by all physicians to improve the system. For the full report, please contact


Learn more about the Partnerships Pillar.

This pillar group was established after our last active project intake, so there have not yet been projects completed under this pillar.

Physician Input into Governance

Learn more about Physician Input to Governance here.

Completed Projects:


Enhancing Physician Input into Development and Review of Interdisciplinary and Nursing Practice Standards – Dr. Martin Trotter
An opportunity for physician experts and stakeholders have input into the development and review of interdisciplinary and nursing practice standards.

Palliative Care: Physician Governance in Action to Support Program Change – Dr. Julia Raudzus/Dr. Gil Kimmel 
A project identifying the key elements to better support program change with physicians and Allied Health Professionals (AHP) in the Palliative Care team. Possible implementation of such learning will be shared with another team with a similar working model.

St. Paul's Redevelopment and Transformation

Learn more about Medical Staff and the New St. Paul’s Hospital here.

Completed Projects:


Centralized Referral Intake for elbow, wrist, and hand problems   – Dr. Jeff Pike
A project to implement a centralized simpler referral process by decreasing waiting time to less than 3 months for patients with elbow, wrist and hand problems within 8 months of implementation at SPH.

Development of the multidisciplinary surgical skills laboratory – Dr. Kathryn Isaac
A project to establish a working group of surgeons for the new surgical simulation center under an overarching SPH Simulation center.


Redevelopment and Modernization of Acute Internal Medicine Service at SPH – Dr. Terence Yung
Develops a proposal on the structure and operation of a new acute medicine service at the current and new SPH with strong input from the physician community. Click here for final report. 

St. Paul’s Emergency Department Redevelopment Engagement Initiative – Dr. Mattias Berg, Dr. Julian Marsden
A project to increase emergency physician (EP) awareness and engagement into the planning for the new ED. Foundational to this is a a new vision of how we provide care for patients in the future.


Learning from other Palliative Care Teams – Dr. Gil Kimel
Funded by the PASS “Facility Tours – Conference Extender” program. A project to provide meaningful contributions to the design details (not overall structural layout) of the new Palliative Care Unit in the new SPH, by visiting and learning from other Palliative Care Units. Click here for final report. 

Learnings from Kaiser Permanente  – Dr. Jeff Pike
A project proposing actionable items to advance the Facility Engagement (FE) mission from a 3-day visit to a successful health care organization.

Re-engaging Family Physicians with PHC – Dr. Fraser Norrie
A series of evening consultations to re-engage community family physicians who have or once held privileges at PHC, determine their priorities, get their input into redevelopment, and support them to move into leadership and governance roles. Click here for final report. 

New St. Paul's Vision Supporting Projects (via SSC Health System Redesign Funds)

Learn more about Medical Staff and the New St. Paul’s Hospital here.


New Ideas for a New Building: Introducing Value-Based Health Care to the Dept of Medicine – Dr. Kristine Chapman
A project developing a program to introduce and pilot Value-Based Health Care practices across PHC, beginning with the Department of Medicine, through divisional champions. This will create the foundation for a new collaborative model of care at the New St. Paul’s Hospital. Read more here> 

Optimizing the care and function for people and populations experiencing impairments, disabilities, or diseases at PHC – Dr. Evan Kwong
A project to develop a strategic plan to align the Division of Physical Medicine & Rehabilitation with the NSP vision of integrated models of care, and PHC’s 7-year Mission-forward strategic priorities. Read more here>

A Primary Maternity Care Framework for NSPH – Dr. Jennifer Leavitt & co-leads Dr. Evelyne Perron & Patricia Rohlfs, RM
A project to build a shared family practice-midwifery model of care for the future state of maternity care at the New St. Paul’s Hospital. Read more here>

Creating the Vision for the Future of Emergency Care at PHC – Dr. Julian Marsden & co-lead Dr. Mattias Berg
The motivation and enthusiasm of a new hospital affords the opportunity to fundamentally change how we provide exceptional emergency care not only at the New St Paul’s/PHC but to do so as leaders provincially and nationally over the next 100 years and beyond–this project aims to develop a plan that articulates this vision. Read more here>

Building Molecular Imaging While We Build The New St. Paul’s Hospital – Dr. Darra Murphy & co-lead Dr. Moira Stilwell
A project to develop a plan that actively moves the Medical Imaging Department towards the modern imaging paradigm that will be a requirement in the New St. Paul’s Hospital, allowing us the best diagnostic facilities and therefore treatment for our patients. Read more here>

Re-Imagining Care Delivery in the New Critical Care Complex – Dr. Adam Peets & co-leads Dr. Matt Coley & Dr. Krish Ramanathan
A project to re-imagine and plan the ways in which we may be able to deliver optimal care to some of our most complex and acutely ill patients at the New St. Paul’s.​ Read more here> 

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