Nova Scotia Health Research Articles

A Novel Hybrid Simulated Annealing for No-Wait Open-Shop Surgical Case Scheduling Problems

In this paper, the problem of finding an assignment of “n” surgeries to be presented in one of “m” identical operating rooms (ORs) or machines as the surgical case scheduling problem (SCSP) is proposed. Since ORs are among NP-hard optimization problems, mathematical and metaheuristic methods to address OR optimization problems are used. The job or surgical operation ordering in any OR is a permanent part of all sequencing and scheduling problems. The transportation times between ORs are defined based on the type of surgical operations and do not depend on distance, so there is no surgical operation waiting time for transferring. These problems are called no-wait open-shop scheduling problems (NWOSP) with transportation times. The transportation system for the problems is considered a multi-transportation system with no limitation on the number of transportation devices. Accordingly, this study modeled a novel combined no-wait open-shop surgical case scheduling problem (NWOSP-SCSP) with multi-transportation times for the first time to minimize the maximum percentile of makespan for OR as a single objective model. A mixed-integer linear program (MILP) with small-sized instances is solved. In addition to the small-sized model, a novel metaheuristic based on a hybrid simulated annealing (SA) algorithm to solve large-sized problems in an acceptable computational time is suggested, considering the comparison of the SA algorithm and a new recommended heuristic algorithm. Then, the proposed hybrid SA and SA algorithms are compared based on their performance measurement. After reaching the results with a numerical analysis in Nova Scotia health authority hospitals and health centers, the hybrid SA algorithm has generated significantly higher performance than the SA algorithm.

EARLY DETECTION AND MANAGEMENT OF FRAILTY IN PRIMARY CARE: VALIDATION OF THE EFI-CGA WITH ELECTRONIC HEALTH RECORDS

Abstract Background Frailty is common in older adults and associated with many adverse outcomes. To promote early detection and management of frailty outside specialized geriatric services, we developed an electronic Frailty Index based on a Comprehensive Geriatric Assessment (eFI-CGA) in electronic health records. Here, we compare the eFI-CGA assessments between family physicians (FP) and geriatricians (GM). Methods Data from community-dwelling older adults were collected as part of the collaborative effort between Fraser Health and Nova Scotia Health to validate the eFI-CGA. The eFI-CGA was created following a standard procedure based on understanding deficit accumulation. A FP and a GM assessed each patient independently. Characteristics of the eFI-CGA were examined for each physician group using descriptive statistics and correlation analysis. FP-GM inter-rater reliability was tested using Cohen’s Kappa. Results The first 30 cases were aged 80.8±5.2 years; 7% were women; with 12.9±2.8 years of education; 17% lived alone. Mild cognitive impairment or dementia was present in 20% participants. The mean clinical frailty scale (CFS) was 3 and the mean eFI-CGA was 0.20 by both FP and GM ratings. The CFS and eFI-CGA were closely correlated (r=0.76 for FP and r=0.71 for GM, p<.001). The eFI-CGA also showed an age correlation (r values >0.37, p values <.050). The average intraclass correlation coefficient was 0.79 for CFS and 0.90 for eFI-CGA (each p<.001). Conclusion Frailty data collected in primary care are highly comparable with geriatrician assessments. Ongoing work will test the generalizability of these findings using a larger sample with follow-up and outcomes evaluations.

An Innovative and Comprehensive Approach to Nursing Workforce Sustainability in Nova Scotia.

The COVID-19 pandemic has revealed long-standing deficiencies with existing nurse recruitment and retention approaches, resulting in critical shortages of nursing capacity that are set to worsen without appropriate action. Decades of evidence and experience suggest that a multi-pronged approach that fosters an enabling and supportive work environment for nurses across all stages of their working lifespan will be required to build a more sustainable nursing workforce. This paper demonstrates Nova Scotia's innovation in creating a comprehensive, evidence-informed approach to nursing workforce planning and management, including key strategic areas of action related to (1) facilitating entry into the workforce, (2) investing in the active workforce and (3) enhancing support for and managing attrition of the workforce. This paper also offers nursing leaders a series of reflections on current learnings in the implementation of this innovative and person-centred approach to nursing workforce sustainability. Recognizing the pressing need for action, Nova Scotia Health and provincial leaders have and are implementing strategic innovations to enhance the nursing workforce. These include: (1) investment in organizational capacity for evidence-based innovation, (2) development of collaborative relationships between both internal stakeholders and community partners and (3) creation of mechanisms for meaningful engagement and co-design of locally relevant innovative solutions.

Workers’ compensation board claims and emergency department diagnostic management of non-specific low back pain

Background: Low back pain is a leading cause of disability worldwide and results in enormous healthcare and lost productivity costs. Guidelines exist to guide the management of low back pain, but guideline adherence varies.Objective: This study assessed whether initial presentation to the emergency department for non-specific low back pain with a Workers’ Compensation Board of Nova Scotia claim was associated with different diagnostic management from non-claimants.Methods: In this retrospective cohort study, we analyzed administrative data from four emergency departments in Nova Scotia on 18,337 adult patients who presented for non-specific low back pain between July 15, 2009 and May 1, 2019. All data were retrieved from the Nova Scotia Health Authority Emergency Department Information System.Results: Patients had a mean age of 43 years and 51.3% were female. Most patients were assigned a Canadian Triage Acuity Scale score of 3 (51.9%) and reported moderate (51.2%) to severe pain (41.5%). Occupational injuries consisted of 11.6% of visits. More than 37% of patients received one or more diagnostic test. Patients with occupational injuries were less likely to receive diagnostic tests (odds ratio [OR] = 0.52, 95% CI 0.47 to 0.58), imaging (OR = 0.60, 95% CI 0.54 to 0.67), and laboratory tests (OR = 0.35, 95% CI 0.29 to 0.43). These results remained consistent when controlling for covariates.Conclusion: Patients who presented to the emergency department for occupational non-specific low back pain were less likely to receive diagnostic tests compared to non-occupational non-specific low back pain patients.

Developing, Implementing, and Evaluating an Artificial Intelligence-Guided Mental Health Resource Navigation Chatbot for Health Care Workers and Their Families During and Following the COVID-19 Pandemic: Protocol for a Cross-sectional Study.

BackgroundApproximately 1 in 3 Canadians will experience an addiction or mental health challenge at some point in their lifetime. Unfortunately, there are multiple barriers to accessing mental health care, including system fragmentation, episodic care, long wait times, and insufficient support for health system navigation. In addition, stigma may further reduce an individual’s likelihood of seeking support. Digital technologies present new and exciting opportunities to bridge significant gaps in mental health care service provision, reduce barriers pertaining to stigma, and improve health outcomes for patients and mental health system integration and efficiency. Chatbots (ie, software systems that use artificial intelligence to carry out conversations with people) may be explored to support those in need of information or access to services and present the opportunity to address gaps in traditional, fragmented, or episodic mental health system structures on demand with personalized attention. The recent COVID-19 pandemic has exacerbated even further the need for mental health support among Canadians and called attention to the inefficiencies of our system. As health care workers and their families are at an even greater risk of mental illness and psychological distress during the COVID-19 pandemic, this technology will be first piloted with the goal of supporting this vulnerable group.ObjectiveThis pilot study seeks to evaluate the effectiveness of the Mental Health Intelligent Information Resource Assistant in supporting health care workers and their families in the Canadian provinces of Alberta and Nova Scotia with the provision of appropriate information on mental health issues, services, and programs based on personalized needs.MethodsThe effectiveness of the technology will be assessed via voluntary follow-up surveys and an analysis of client interactions and engagement with the chatbot. Client satisfaction with the chatbot will also be assessed.ResultsThis project was initiated on April 1, 2021. Ethics approval was granted on August 12, 2021, by the University of Alberta Health Research Board (PRO00109148) and on April 21, 2022, by the Nova Scotia Health Authority Research Ethics Board (1027474). Data collection is anticipated to take place from May 2, 2022, to May 2, 2023. Publication of preliminary results will be sought in spring or summer 2022, with a more comprehensive evaluation completed by spring 2023 following the collection of a larger data set.ConclusionsOur findings can be incorporated into public policy and planning around mental health system navigation by Canadian mental health care providers—from large public health authorities to small community-based, not-for-profit organizations. This may serve to support the development of an additional touch point, or point of entry, for individuals to access the appropriate services or care when they need them, wherever they are.International Registered Report Identifier (IRRID)PRR1-10.2196/33717

Operationalizing integrated needs-based workforce planning at Nova Scotia Health in response to the COVID-19 pandemic.

This paper documents Nova Scotia Health’s progress in operationalizing integrated needs-based workforce planning as part of its ongoing response to the pandemic. A multidisciplinary workforce planning team with representation spanning key portfolios was created to facilitate the organization’s response to the pandemic. Analyses applied early in Wave 3 of the pandemic showed large projected shortages in several professions and identified which services would likely be scarcest among the available workforce relative to patient need. Based on these results, the workforce planning team recommended and supported operational teams in implementing a multi-faceted set of interventions aimed at increasing the availability of individuals with these competencies. These interventions collectively yielded an adequate supply of additional competent personnel to meet the needs of COVID-19 inpatients across the province through the third wave of the pandemic. Lessons learned are proving critical to maintaining core operations during Wave 4 of the pandemic.

SABA use as an indicator for asthma exacerbation risk: an observational cohort study (SABINA Canada).

BackgroundPatients with asthma use short-acting β-agonists (SABA) to relieve symptoms but SABA alone does not treat underlying inflammation. Thus, over-reliance on SABA may result in poor asthma control and negative health outcomes.ObjectiveTo describe use of SABA and characterise the relationship with severe exacerbations in the Canadian provinces of Nova Scotia (NS) and Alberta (AB).MethodsIn this longitudinal Canadian SABA In Asthma (SABINA) study, patients with an asthma diagnosis were identified between 2016 and 2020 within two provincial administrative datasets (Health Data Nova Scotia and Alberta Health Services). All patients were followed for ≥24 months, with the first 12 months used to measure baseline asthma severity. Medication use and the relationship of SABA overuse (three or more canisters per year) with severe asthma exacerbations were characterised descriptively and via regression analysis.ResultsA total of 115 478 patients were identified (NS: n=8034; AB: n=107 444). SABA overuse was substantial across both provinces (NS: 39.4%; AB: 28.0%) and across all baseline disease severity categories. Patients in NS with SABA overuse had a mean±sd annual rate of 0.46±1.11 exacerbations, compared to 0.30±1.36 for those using fewer than three canisters of SABA. Patients in AB had mean±sd exacerbation rates of 0.31±0.86 and 0.17±0.62, respectively. The adjusted risk of severe exacerbation was associated with SABA overuse (NS: incidence ratio rate 1.36, 95% CI 1.18–1.56; AB: incidence ratio rate 1.32, 95% CI 1.27–1.38).ConclusionThis study supports recent updates to Canadian Thoracic Society and Global Initiative for Asthma guidelines for asthma care. SABA overuse is associated with increased risk of severe exacerbations and can be used to identify patients at a higher risk for severe exacerbations.

The Impact of Resistance Exercise on Muscle Mass in Glioblastoma in Survivors (RESIST): Protocol for a Randomized Controlled Trial.

BackgroundGlioblastoma is the most common primary brain malignancy in adults, accounting for approximately 48% of all brain tumors. Standard treatment includes radiation and temozolomide chemotherapy. Glioblastomas are highly vascular and can cause vasogenic brain edema and mass effect, which can worsen the neurologic symptoms associated with the disease. The steroid dexamethasone (DEX) is the treatment of choice to reduce vasogenic edema and intracranial pressure associated with glioblastoma. However high-dose DEX or long-term use can result in muscle myopathy in 10%-60% of glioblastoma patients, significantly reducing functional fitness and quality of life (QOL). There is a wealth of evidence to support the use of exercise as an adjuvant therapy to improve functional ability as well as help manage treatment-related symptoms. Specifically, resistance training has been shown to increase muscle mass, strength, and functional fitness in aging adults and several cancer populations. Although studies are limited, research has shown that exercise is safe and feasible in glioblastoma populations. However, it is not clear whether resistance training can be successfully used in glioblastoma to prevent or mitigate steroid-induced muscle myopathy and associated loss of function.ObjectiveThe primary purpose of this study is to establish whether an individualized circuit-based program will reduce steroid-induced muscle myopathy, as indicated by maintained or improved functional fitness for patients on active treatment and receiving steroids.MethodsThis is a 2-armed, randomized controlled trial with repeated measures. We will recruit 38 adult (≥18 years) patients diagnosed with either primary or secondary glioblastoma who are scheduled to receive standard radiation and concurrent and adjuvant temozolomide chemotherapy postsurgical debulking and received any dose of DEX through the neurooncology clinic and the Nova Scotia Health Cancer Center. Patients will be randomly allocated to a standard of care waitlist control group or standard of care + circuit-based resistance training exercise group. The exercise group will receive a 12-week individualized, group and home-based exercise program. The control group will be advised to maintain an active lifestyle. The primary outcome, muscle myopathy (functional fitness), will be assessed using the Short Physical Performance Battery and hand grip strength. Secondary outcome measures will include body composition, cardiorespiratory fitness, physical activity, QOL, fatigue, and cognitive function. All measures will be assessed pre- and postintervention. Participant accrual, exercise adherence, and safety will be assessed throughout the study.ResultsThis study has been funded by the Canadian Cancer Society Atlantic Cancer Research Grant and the J.D. Irving Limited–Excellence in Cancer Research Fund (grant number 707182). The protocol was approved by the Nova Scotia Health and Acadia University’s Research Ethics Boards. Enrollment is anticipated to begin in March 2022.ConclusionsThis study will inform how individualized circuit-based resistance training may improve functional independence and overall QOL of glioblastoma patients.Trial RegistrationClinicalTrails.gov NCT05116137; https://www.clinicaltrials.gov/ct2/show/NCT05116137International Registered Report Identifier (IRRID)DERR1-10.2196/37709

The Network of Scholars Strategy: A Case Study of Embedded Research Activities in Nova Scotia to Advance Health System Impact and Outcomes.

The Canadian Institutes of Health Research - Institute of Health Services and Policy Research's (IHSPR's) Strategic Plan 2021-2026 for accelerating health system transformation is well positioned to meet the strategic priorities being outlined by many health systems in Canada and internationally (CIHR IHSPR 2021). The IHSPR Health System Impact Fellow program has been a strong influence on the embedded research and scientist program in Nova Scotia, namely, the Network of Scholars Program, which was implemented just before the pandemic. The network includes scientists and scholars from diverse academic backgrounds and skill levels including alumni of the Health System Impact Fellow program. The Network of Scholars has over 30 scholars and approximately 100 academic partners and scientists supporting embedded activities such as rapid reviews, implementation science and rapid evaluation initiatives. These embedded activities are front facing to the needs and priorities of the health system. This commentary highlights the importance of IHSPR's outlined strategic plan and direction, which are consistent with the experience and the needs for embedded supports within the Nova Scotia health system.

CUP study: protocol for a comparative analysis of centralised waitlist effectiveness, policies and innovations for connecting unattached patients to primary care providers

IntroductionAccess to a primary care provider is a key component of high-functioning healthcare systems. In Canada, 15% of patients do not have a regular primary care provider and are classified...

Stress and Burnout Among Mental Health Staff During the COVID-19 Pandemic.

The coronavirus disease 2019 (COVID-19) pandemic has deeply altered social and working environments among health care workers. These health care workers are therefore at risk of additional psychosocial strain and ensuing metal health symptoms, which indirectly affects patient care. In this study, we aimed to assess the psychosocial and psychopathological impact of COVID-19 among acute care mental health and addictions staff. This study is a cross-sectional survey and contains a sample size of 60 mental health and addiction acute care workers recruited from within Nova Scotia Health Authority. The survey was constructed using the online survey system, Opinio, and consisted of three sections: demographic variables (gender, age group and profession); the DASS-21 Questionnaire (which provides dimensional measures of stress, anxiety and depression); and the MBI-HSS (MP) Questionnaire (which measures three dimensions of burnout-emotional exhaustion, depersonalization and personal achievement). The majority of participants had at least one pathologic score on the DASS-21 and MBI-HSS (MP) sections (75.5% and 93.5%, respectively). The median severity on the DASS-21 and MBI-HSS (MP) were both moderate, with the younger age group (20-35 years) having more significant burnout scores (p = 0.0494). Simple logistic regression showed a significant relationship between burnout severity and pathologic distress, and simple linear regression showed significant correlation between DASS-21 and MBI-HSS (MP) scores, with a R2 value of 0.4633. More planning, programs, resources and further research are needed to support wellness and recovery of all health care professionals who work at the mental health and addictions acute care unit.

Evidence to Care: Learning from a Case Study of Health Workforce Planning and COVID-19 Response in Nova Scotia.

Repeated calls to adopt more robust workforce planning, particularly for the nursing workforce, stretch back decades. These calls have generally not been met with action by health system decision makers, and the negative consequences - widespread shortages, even in wealthy countries, and decreased quality of care despite increased costs - have come to pass much as predicted. In contrast to this historical pattern, this paper presents Nova Scotia Health's experience in planning for its critical care nursing workforce during COVID-19 as a case study in integrating evidence-based workforce planning into the operations of a healthcare organization.

Problems in Coordinating and Accessing Primary Care for Attached and Unattached Patients Exacerbated During the COVID-19 Pandemic Year (the PUPPY Study): Protocol for a Longitudinal Mixed Methods Study.

BackgroundThe COVID-19 pandemic has significantly disrupted primary care in Canada, with many walk-in clinics and family practices initially closing or being perceived as inaccessible; pharmacies remaining open with restrictions on patient interactions; rapid uptake of virtual care; and reduced referrals for lab tests, diagnostics, and specialist care.ObjectiveThe PUPPY Study (Problems in Coordinating and Accessing Primary Care for Attached and Unattached Patients Exacerbated During the COVID-19 Pandemic Year) seeks to understand the impact of the COVID-19 pandemic across the quadruple aims of primary care, with particular focus on the effects on patients without attachment to a regular provider and those with chronic health conditions.MethodsThe PUPPY study builds on an existing research program exploring patients’ access and attachment to a primary care practice, pivoted to adapt to the emerging COVID-19 context. We intend to undertake a longitudinal mixed methods study to understand critical gaps in primary care access and coordination, as well as compare prepandemic and postpandemic data across 3 Canadian provinces (Quebec, Ontario, and Nova Scotia). Multiple data sources will be used such as a policy review; qualitative interviews with primary care policymakers, providers (ie, family physicians, nurse practitioners, and pharmacists), and patients (N=120); and medication prescriptions and health care billing data.ResultsThis study has received funding by the Canadian Institutes of Health Research COVID-19 Rapid Funding Opportunity Grant. Ethical approval to conduct this study was granted in Ontario (Queens Health Sciences & Affiliated Teaching Hospitals Research Ethics Board, file 6028052; Western University Health Sciences Research Ethics Board, project 116591; University of Toronto Health Sciences Research Ethics Board, protocol 40335) in November 2020, Québec (Centre intégré universitaire de santé et de services sociaux de l'Estrie, project 2020-3446) in December 2020, and Nova Scotia (Nova Scotia Health Research Ethics Board, file 1024979) in August 2020.ConclusionsTo our knowledge, this is the first study of its kind to explore the effects of the COVID-19 pandemic on primary care systems, with particular focus on the issues of patient’s attachment and access to primary care. Through a multistakeholder, cross-jurisdictional approach, the findings of the PUPPY study will inform the strengthening of primary care during and beyond the COVID-19 pandemic, as well as have implications for future policy and practice.International Registered Report Identifier (IRRID)DERR1-10.2196/29984

Predictive Factors of Overall Survival and the Completion of Four Cycles of Azacitidine: An MDS-CAN Study

Predictive Factors of Overall Survival and the Completion of Four Cycles of Azacitidine: An MDS-CAN Study

An MDS Specific Frailty Index Based on Cumulative Deficits Adds Independent Prognostic Value to Established Clinical Prognostic Scoring Systems

An MDS Specific Frailty Index Based on Cumulative Deficits Adds Independent Prognostic Value to Established Clinical Prognostic Scoring Systems

Low Rate of Guideline Adherence for the Diagnosis and Management of Adrenal Incidentalomas in the Nova Scotia Health Authority Central Zone

Abstract Background: Adrenal incidentalomas are prevalent and clinically significant, yet are often overlooked by clinicians. The objective of this study was to retrospectively examine the adherence to American College of Radiology (2017) and European Endocrine Society (2016) guidelines for the diagnosis and management of adrenal incidentalomas within a centre servicing a population of over 400,000. Methods: Relevant computed tomography (CT) and magnetic resonance (MR) scans from February 17th, 2019 to December 18th, 2019 were consecutively reviewed for the presence of adrenal incidentalomas. Radiographic reports and original imaging were reviewed to evaluate the completeness of reporting. A chart review was conducted to determine if biochemical investigations for cases were undertaken and whether referral to Endocrinology was made. Reports were checked for the inclusion of an addendum recommending Endocrinology referral. Results: A convenience sample of 148 cases were included in the study, with 176 distinct adrenal incidentalomas identified. Where relevant, attenuation values were provided for 20% of cases, and follow-up imaging was recommended in 59% of cases. Of the 124 cases where biochemical investigation was deemed appropriate, a complete work-up was conducted in 4% of cases, and 11% were referred to Endocrinology. Follow-up imaging was ordered appropriately in 36% of cases, and no cases had inappropriate follow-up imaging. The addendum was included for 19% of cases, and it did not impact biochemical investigation rates but did improve Endocrinology referral rates. Conclusions: There is poor adherence to guidelines for the diagnosis and management of adrenal incidentalomas within our study population. This poor adherence would be an ideal target for quality improvement initiatives, in order to minimize missed functional and malignant adrenal masses.

Application of unsupervised machine learning to identify areas of blood product wastage in transfusion medicine.

Wastage of blood products can be a significant cost to blood banks. However, the cause of wastage is often complex and makes it difficult to determine wastage-associated factors. Machine learning techniques may be useful tools to investigate these complex associations. We investigated whether unsupervised machine learning can identify patterns associated with wastage in our blood bank. Data on red blood cells, platelets and frozen products were obtained from the laboratory information system of the Central Zone Blood Transfusion Services at Nova Scotia Health Authority. A total of 879532 transactions were analysed by association rule mining, a type of machine learning algorithm. Associations with lift scores greater than 25 and with clinical relevance were flagged for further examination. Association rule mining returned a total of 3355 associations related to wastage. Several notable associations were identified. For example, certain wards were associated with wastage due to thawing unused frozen products. Other examples included association between smaller blood banks and evening work shifts with product wastage due to excess time outside the laboratory or returning products with high temperatures. This paper demonstrates the effective use of unsupervised machine learning for the purpose of investigating wastage in a large blood bank. The use of association rule mining was able to identify wastage factors, which can help guide quality improvement initiatives. This technique can be automated to provide rapid analysis of complex associations contributing to wastage and could be utilized in modern blood banks.

Variable effects of obesity on access to total hip and knee arthroplasty.

BackgroundObesity is an important comorbidity affecting outcomes after total joint arthroplasty. Consequently, surgeons may delay care of obese patients to first address obesity through different care pathways. The effect of obesity on patient wait times for total joint arthroplasty has not been explored. The purpose of this study was to evaluate the effect of obesity on access to total hip (THA) and knee (TKA) arthroplasty.MethodsThe study data set was constructed from the Nova Scotia Health Authority’s Horizon Patient Folder system and the Patient Access Registry Nova Scotia. Wait time was measured as days between the decision to treat and date of surgery. Body mass index (BMI) was calculated from a preoperative assessment, and patients were grouped into BMI categories. Multivariate log-linear regression was used to test for statistical differences, controlling for confounding factors.ResultsWe observed longer wait times for TKA with increasing BMI weight class. Patients with BMIs greater than 50 had 34% longer waits than reference weight patients. However, THA recipients showed no statistical difference in wait times across weight categories. Furthermore, there was variability among surgeons in the wait times experienced by patients.ConclusionThe finding of longer wait times for TKAs, but not THAs, among patients who were obese was unexpected. This shows the variable wait times for THA and TKA that patients who are obese can experience with different surgeons. It is important to understand the variability in wait times so that efforts to standardize the patient experience can be accomplished.

Assessing the Representation of People of African Descent on Nova Scotia’s Community Health Boards

According to the Health Authorities Act (Section 62), Community Health Boards (CHBs) in Nova Scotia are intended to “contribute to health-system accountability by facilitating an exchange of information and feedback between the community and the provincial health authority.” The present situation, however, is one in which health boards may not represent the demographic diversity of the community. This challenge may be particularly prevalent within African Nova Scotian communities. This paper will quantify whether people of African descent who serve on CHBs match the demographics of the community and discuss whether any discrepancies may affect policy initiatives within Nova Scotia Health. To answer these questions, we conducted a demographic analysis of 31 CHBs. The representation of African Nova Scotian participants on CHBs (5%) exceeds their representation within the total provincial population (2.4%); however, by removing the Southeastern Board, the representation of African Nova Scotians mirrors their representation in Nova Scotia as a whole. African Nova Scotians are overrepresented, to some extent, on CHBs. This overrepresentation is a factor of small sample size and skewed distribution. Even in historically African Nova Scotian communities like the Southeastern Board (with 85% of residents identifying as African Nova Scotians), the board demographics do not match the demographics of the communities they serve. Given the unique challenges African Nova Scotians face within Nova Scotia’s health system, representation on all boards may be necessary. The challenges of robust engagement of marginalized communities could be addressed by dedicated recruitment efforts by Nova Scotia Health. Further, the lack of demographic information collected by either CHBs or by Nova Scotia Health presents an inability to address critical concerns within the African Nova Scotian community.

Setting the standard for healthy eating: Continuous quality improvement for health promotion at Nova Scotia Health.

Healthcare organizations engage in continuous quality improvement to improve performance and value-for-performance, but the pathway to change is often rooted in challenging the way things are "normally" done. In an effort to propel system-wide change to support healthy eating, Nova Scotia Health developed and implemented a healthy eating policy as a benchmark to create a food environment supportive of health. This article describes the healthy eating policy and its role as a benchmark in the quality improvement process. The policy, rooted in health promotion, sets a standard for healthy eating and applies to stakeholders both inside and outside of health. We explain how the policy offers nutrition but also cultural benchmarks around healthy eating, bringing practitioners throughout Nova Scotia Health together and sustaining collaborative efforts to improve upon the status quo.