We invested a great amount of resources in involving all the medical staff and health care professionals who work with our COPD clientele, not only from each department and site, but also from all the different hierarchical levels, particularly at the decision making level.

We organized three focus groups¹ (one at each site) to discuss barriers/obstacles and identify possible solutions. These obstacles were then ranked by priority as follows.

Barriers detected included:

• poor access and poor quality of spirometry tests;
• high turnover rates for residents and nursing staff; and
• lack of standardization in medical practices.

Solutions that were suggested:

• increased access to spirometry tests (collective order to allow spirometry test order by specialized nurses clinicians);
• continuous training of the residents and nurses;
• increase awareness of which services are available for COPD patients;
• built a standardized tools to plan the discharge of COPD patients; and
• provide additional nursing resources to assessing COPD patients, doing some teaching interventions and provide adequate information to increase and facilitate the reference to respiratory services in the community.

Select suitable interventions to facilitate, enable and reinforce the change and to overcome barriers/obstacles

Following the focus groups and further discussions at the RECAP-MUHC Committee, the key interventions were defined:

• Resources: The Associate Director of Nursing at the MUHC agreed that the specialized nurse clinicians in internal medicine of the two general's hospitals sites would be responsible for COPD clientele management in the internal medical units. To this effect, these nurses would be in charge of ensuring the follow up with regard to the optimal management of COPD patients during admission and especially at discharge. Eventually, they will offer continuous training to the personnel in their medical unit (nurses, residents, etc.). More importantly, this represents a success for the RECAP project, since now we have professionals on site, working together to find solutions specific to their own environment (resources, barriers, etc). We succeeded in convincing Respiratory Services and Emergency Room managers of the importance of spirometry testing during admission and ER visits, and of the need for specialized resources (respiratory therapists).
  
  After almost two years of process, we now have a respiratory therapist in one of the two general's hospital emergency departments. Her tasks include doing spirometry, offer minimal intervention and assuring the link with others resources available in the institution and territory. The other general hospital has the money to hire a respiratory therapist but they do not have enough personnel.

• Tools: The RECAP MUHC committee supported the specialized nurse clinicians and a discharge planning tool (example 1, see below) was created as a reminder. It contains components of the optimal treatments and appropriate services to be offered to COPD clientele. The specialized nurse clinicians can also directly call upon COPD nurses at the MCI clinic to answer clinical questions related to the management of COPD patients (medication, need for pulmonary rehabilitation, etc.).
  
  A collective order request was done to allow specialized nurse clinicians in internal medicine ordering a spirometry test. After two years of process, the specialized nurse clinicians in internal medicine can now order a spirometry test.

• Process: In addition to these interventions (discharge planning tool), we created a specific clinical pathway (COPD Care Map) for COPD patients in the respiratory medical unit at the Montreal Chest Institute (respiratory hospital) which involve are involving a multi-disciplinary team instead of only the specialized nurse clinicians in internal medicine at the two general hospitals (example 2, see below).

Our intervention plan examples

 [1] Focus groups included doctors (medical units, ER), respirologists, chief nurses and nursing staff.

By identifying obstacles to adherence, and including healthcare professional perspectives on potential barriers and their solutions to bridge the gaps in care, a more successful intervention can be achieved.