A culture of quality improvement: The Ottawa Hospital’s adoption of MCC 360

MCC 360 is a national multi-source feedback program helping health care professionals to better understand their practice, including their strengths and areas for improvement, by collecting and collating feedback from colleagues, co-workers, and patients. Many health care professionals are invited to participate in the MCC 360 program by their hospitals, regional health authorities, and medical regulatory authorities to support a regular cycle of continuing professional development activities and cyclical quality improvement.

The Ottawa Hospital (TOH) has been an MCC 360 user since 2021, receiving over 250 reports to date.

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Reviews for physicians, dental surgeons, and midwives alike

As part of medical staff bylaw requirements at TOH, in-depth performance reviews like a 360 review, need to be completed at the two-year employment mark.

All medical staff are subject to this review, including the midwives who work out of TOH. This makes TOH the first organization to use the MCC 360 program with midwives. There were no significant changes that needed to be made to MCC 360 to include midwives. The MCC simply changed the language presented in the surveys from “physician” to “MCC 360 participant.” “Our hope was not to do anything different, other than make sure that it resonated, regardless of what your credentialing category was,” explains Tracy Wrong, Director of Medical Affairs, Patient Relations and Health Records. Part of this ease of adaptation lies in the intention behind MCC 360; the tool was developed with all medical professionals in Canada in mind, not just physicians.

An administrative win

The previous quality tool used by TOH was discontinued, and following an RFP process to replace that tool, the MCC’s program was selected. A key highlight behind the selection decision for TOH was that MCC 360 is a Canadian tool, with all data stored in Canada. The processes to collect feedback were also similar to the previous tool it had worked with, and staff drew confidence from the way MCC 360 had been developed: both the rigorous, evidence-based creation of the tool and the medical expertise behind it.

Administratively, it was easy to transfer to MCC 360. Having a single online portal where participants are directed works well. “Having the portal online and being able to see exactly how many patient surveys have come in is really good because we used to wait to receive an Excel spreadsheet,” says Tracy.

For over 10 years, TOH has been requiring 360 reviews for their medical staff, which is pretty unique in the hospital landscape. Reviews like this can be seen as challenging administratively, especially for smaller hospitals where their Medical Affairs department might wear many hats, in terms of the responsibilities they have. Though, Tracy tells us, “We’re not a huge department either. Basically, once MCC 360 is up and running, it’s not onerous. It’s easy for us to talk positively about it because it’s worked very well, and the longer we use it, the more comfortable we get with what the information is telling us and how to interpret it.”

Structured feedback collection

“The MCC 360 team is very responsive, and that helps us on our end when we’re trying to give guidance to complete the review process,” explains Angela Lambert, Program Lead, Medical Affairs.

Tracy and Angela do their best to support and guide the medical staff through their collection of feedback for MCC 360; they see themselves as the conduit to making sure each medical professional meets their bylaw requirement. Once each report is generated, it’s simply a tool for the benefit of the medical professional; the Medical Affairs team will not edit the report or look for negative feedback. “That being said, it’s in our bylaws for a reason. It really is about ensuring that the new staff member has an opportunity to have a quality improvement, self-reflective moment in their practice between their second and their third year with TOH,” explains Tracy.

While there may be different ways for practitioners to receive feedback from colleagues throughout their careers, MCC 360 is a very structured way to receive patient feedback. “Even, the Chief of Staff has expressed that this is possibly the one time in your career that you will get to ask patients for their feedback,” adds Tracy.

Occasionally, some medical staff groups need to be excluded from the patient feedback component of MCC 360, such as medical lab staff who may not interact with patients directly. The Chief of Staff will ultimately make this decision, though exceptions are made very infrequently.

Like many other organizations who use MCC 360, TOH sees the program as a structured component of a larger review process. Many of the medical staff receive really good MCC 360 results and don’t necessarily have clear actions to take for improvement. In those cases, MCC 360 feedback becomes input for the annual reappointment conversation, where quality improvement opportunities are discussed.

A culture of quality improvement

Embedding an MCC 360 review as part of the employment process means everyone knows what to expect. “Not every hospital makes a 360 mandatory, but doing so embeds the importance of quality improvement,” says Tracy. “This is what we expect. You’re working at an academic health science center, a teaching hospital, and we expect you and your specialty to be thinking about your practice and getting feedback from others on your practice.”

We asked Tracy what MCC 360 means for the patients that are being seen at TOH. “You have a care provider that understands self-reflection and cares about what they are doing. Ultimately, that translates into better care for patients.”

For more information, visit MCC 360.