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For Patients: Chronic Disease Management

Initial appointments with a PCN health care professional may take as long as one hour.  Follow-up appointments may take as long as thirty minutes.

For Providers: Practice Improvement


​​​ Palliser PCN Health Homes (clinics) are central to the delivery of efficient and effective primary health care. Practice Improvement Facilitators collaborate with primary care teams to optimize healthcare delivery in the Health Home.
PCN Facilitators assist Health Homes with:

Pane​l verifying:​

•  Developing processes to confirm and verify patients within the practice

•  Developing processes to remove patients no longer part of the practi​ce

Access improvement:

•  Measuring access, demand, supply, no-shows, etc.

•  Identifying strategies to improve or maintain access

•  Improving appointment booking process to optimize physician scheduling

EMR optimizing:

•  Identifying and selecting optimal method(s) of tracking patient information inside the EMR

•  Documenting EMR processes to be used/shared by Health Home staff

•  Review of documented EMR processes

Screening process optimizing:

•  Measuring and improving opportunistic and outreach screening processes

•  Effective use of the EMR to automate and measure screening work

•  Review of documented screening processes

Team optimizing:

•  Clearly identify and document Health Home team roles

•  Measuring and improving Health Home team's effectiveness

(e.g. morale, communication, trust, culture).

Clinic efficiency:

•  Exam room standardization

•  Appointment prep standardization

•  Measuring & improving clinic efficiencies

•  Procedures standardization

Optimizing relationships with external stakeholders:

•  Improving communications and processes

•  Optimizing the flow of information to and from the Health Home

Clinic HR, management & new clinic start up support:

•  Developing a clinic handbook

•  Supporting the development of job descriptions, pay scales, employee contracts, performance reviews, & patient satisfaction surveys

•  Supporting teams through change

•  Effective communication techniques

•  Providing in-clinic N95 mask fit testing


•  Creating or Amending Privacy Impact Assessments

•  Providing privacy, confidentiality and security templates

•  Privacy training Hospital discharge improvement:

•  Streamlining communication between clinics and ER/hospital re: patient​ discharge

Clinic team meetings facilitation:

•  Taking minutes and following up on clinic identified actions

•  Ensuring agendas are prepared and meetings run smoothly

•  Delivering custom seminars and workshops

Group medical visit set-up:

•  Linking with outside providers and/or co-presenters

•  Assisting with organization and implementation of successful, in-clinic group visits

•  Providing templates for set-up protocols, invitations, posters, presentations and evaluations

Clinic communications:

•  Developing clinic handouts, brochures, posters

•  Assisting with acquiring HUTV (Health Unlimited TV)

•  Organizing & facilitating clinic manager meetings​

​ ​Your practice improvemenfacilitators:
Doug Frelick

403-580-3825 x 228

​Kimberley MacKinnon

403-580-3825 x 229​​

For more information on Quality Improvement initiatives and to find additional resources, please visit the following website: