Fraser Northwest

Polypharmacy Risk Reduction Initiative

Fraser Northwest

Fraser Northwest family physicians, pharmacists and nurse leaders came together at Polypharmacy Risk Reduction "Building Local Capacity and Sustainability" sessions to develop approaches for conducting meaningful medication review processes in support of the Residential Care Initiative and received tools and clinical resources to support decision making. 



Child and Youth Mental Health Collaborative

Fraser Northwest

Local Action Teams

Local Action Teams (LATs) are a key component in the structure of the Child and Youth Mental Health and Substance Use (CYMHSU) Collaborative. They provide the foundation for improving timely access to support and services for local children, youth and families experiencing mental health and substance use challenges.

Teams are comprised of a diverse cross-section of mental health and substance-use service providers, stakeholders, and youth and families from the local community.

How it works

Each Local Action team commits to tackling one or two key objectives within a particular timeframe to address system barriers in their community. A Collaborative Coach supports the team to help them successfully achieve their goals and measure their outcomes.

A Local Action Team has recently been formed in the Fraser Northwest region. More details regarding who’s involved in this community, and their improvement objectives will be added to this page shortly.

  • New Westminster
  • Tri-Cities


Transitions in Care Initiative

Fraser Northwest

Discharge Planning & Communications - complete

The objective of the Fraser Northwest Division discharge planning project is continuity of care, as patients are admitted into the hospital and then discharged back into the community. This can be achieved by focusing the communication stream from community family physicians (FPs) to hospitalist and back to community FP upon patient discharge.


Partners in Care Initiative

Fraser Northwest

Enhanced Recovery After Surgery (ERAS)

Engaging family physicians in the optimization of ERAS for surgical patients through select pre-operative interventions for colorectal cancer. 

Musculoskeletal (MSK) Medicine

Improving patient access to timely and appropriate MSK care. Patients see a Sports Medicine Physician for an MSK consult and treatment recommendations within 6-8 weeks instead of waiting 12-36+ months to see an Orthopaedic Surgeon. Surgeons are now seeing primarily surgical patients and their wait times have declined dramatically.


Improving the patient journey for respirology patients. Lack of timely access to care is delaying diagnosis and critical treatment, which for many patients means poorer health outcomes.

Pediatrics - Complete

Working with the Youth Transition Shared Care team to improve referrals from GPs to specialists.

Rheumatology - Complete

Developing criteria for urgent vs. non-urgent referrals, embedding referral acknowledgment into the Specialists' EMR, developing materials for improving referrals, establishing a rapid access CI.

Orthopaedics - Complete

FPs and SPs work together to:

  • identify criteria/processes for urgent and non-urgent referrals;
  • develop guidelines for conservative management of non-surgical orthopaedic conditions;
  • make avaiable orthopaedic resources for FPs and patients on our Pathways web site;
  • develop a process for timely acknowledgement of referral requests;
  • implement a pilot project to make an Advanced Practice Physiotherapist available to reduce wait-times for assessment and surgery, and decrease post-surgery recover times.

Psychology/Mental Health - Complete

Working with Fraser Health partners to:

  • Improve the flow of communication from Mental Health Centres (MHC) to FP offices
  • Improve the quality of referral requests to MHCs from FPs
  • Development of Rapid Access Clinics in New Westminster and the Tri-Cities
  • Roll-out the Integrated Care Model into Fraser Northwest

Advance Care Planning - Complete

An advisory committee comprised of family physicians (FPs), specialists (SPs) from several disciplines, hospitalists, a nurse, a Nurse Practitioner, a social worker, and a Fraser Health and community member is crafting a community-based strategy to improve the understanding, take-up and implementation of Advance Care Planning.

Gastroentorology - Complete

Development of referral acknowledgmenent, guidelines for determining level of urgency, information to include with referrals, and "red flags, clinical pearls and workups" for specific conditions that are easilty accessible on the Pathways website.