Marie-Dominique Beaulieu

The conceptual basis for interprofessional collaboration: core concepts and theoretical frameworks.

Interprofessional collaboration is a key factor in initiatives designed to increase the effectiveness of health services currently offered to the public. It is important that the concept of collaboration be well understood, because although the increasingly complex health problems faced by health professionals are creating more interdependencies among them, we still have limited knowledge of the complexity of interprofessional relationships. The goal of this literature review was to identify conceptual frameworks that could improve our understanding of this important aspect of health organizations. To this end, we have identified and taken into consideration: (A) the various definitions proposed in the literature and the various concepts associated with collaboration, and (B) the various theoretical frameworks of collaboration. Our results demonstrate that: (1) the concept of collaboration is commonly defined through five underlying concepts: sharing, partnership, power, interdependency and process; (2) the most complete models of collaboration seem to be those based on a strong theoretical background, either in organizational theory or in organizational sociology and on empirical data; (3) there is a significant amount of diversity in the way the various authors conceptualized collaboration and in the factors influencing collaboration; (4) these frameworks do not establish clear links between the elements in the models and the outputs; and (5) the literature does not provide a serious attempt to determine how patients could be integrated into the health care team, despite the fact that patients are recognized as the ultimate justification for providing collaborative care.

The determinants of successful collaboration: a review of theoretical and empirical studies.

Successful collaboration in health care teams can be attributed to numerous elements, including processes at work in interpersonal relationships within the team (the interactional determinants), conditions within the organization (the organizational determinants), and the organizations environment (the systemic determinants). Through a review of the literature, this article presents a tabulated compilation of each of these determinant types as identified by empirical research and identifies the main characteristics of these determinants according to the conceptual work. We then present a “showcase” of recent Canadian policy initiatives – The Canadian Health Transition Fund (HTF) – to illustrate how the various categories of determinants can be mobilized. The literature review reveals that very little of the empirical work has dealt with determinants of interprofessional collaboration in health, particularly its organizational and systemic determinants. Furthermore, our overview of experience at the Canadian HTF suggests that a systemic approach should be adopted in evaluative research on the determinants of effective collaborative practice.

Practice Features Associated With Patient-Reported Accessibility, Continuity, and Coordination of Primary Health Care

PURPOSE On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict accessibility, continuity, and coordination of care as experienced by patients. METHODS Primary health care clinics were selected by stratified random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on first-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic. RESULTS One hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). First-contact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their office. CONCLUSIONS The way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.

Operational Definitions of Attributes of Primary Health Care: Consensus Among Canadian Experts

PURPOSE In 2004, we undertook a consultation with Canadian primary health care experts to define the attributes that should be evaluated in predominant and proposed models of primary health care in the Canadian context. METHOD Twenty persons considered to be experts in primary health care or recommended by at least 2 peers responded to an electronic Delphi process. The expert group was balanced between clinicians (principally family physicians and nurses), academics, and decision makers from all regions in Canada. In 4 iterative rounds, participants were asked to propose and modify operational definitions. Each round incorporated the feedback from the previous round until consensus was achieved on most attributes, with a final consensus process in a face-to-face meeting with some of the experts. RESULTS Operational definitions were developed and are proposed for 25 attributes; only 5 rate as specific to primary care. Consensus on some was achieved early (relational continuity, coordination-continuity, family-centeredness, advocacy, cultural sensitivity, clinical information management, and quality improvement process). The definitions of other attributes were refined over time to increase their precision and reduce overlap between concepts (accessibility, quality of care, interpersonal communication, community orientation, comprehensiveness, multidisciplinary team, responsiveness, integration). CONCLUSION This description of primary care attributes in measurable terms provides an evaluation lexicon to assess initiatives to renew primary health care and serves as a guide for instrument selection.

Characteristics of primary care practices associated with high quality of care

Background: No primary practice care model has been shown to be superior in achieving high-quality primary care. We aimed to identify the organizational characteristics of primary care practices that provide high-quality primary care. Methods: We performed a cross-sectional observational study involving a stratified random sample of 37 primary care practices from 3 regions of Quebec. We recruited 1457 patients who had 1 of 2 chronic care conditions or 1 of 6 episodic care conditions. The main outcome was the overall technical quality score. We measured organizational characteristics by use of a validated questionnaire and the Team Climate Inventory. Statistical analyses were based on multilevel regression modelling. Results: The following characteristics were strongly associated with overall technical quality of care score: physician remuneration method (27.0; 95% confidence interval [CI] 19.0–35.0), extent of sharing of administrative resources (7.6; 95% CI 0.8–14.4), presence of allied health professionals (15.3; 95% CI 5.4–25.2) and/or specialist physicians (19.6; 95% CI 8.3–30.9), the presence of mechanisms for maintaining or evaluating competence (7.7; 95% CI 3.0–12.4) and average organizational access to the practice (4.9; 95% CI 2.6–7.2). The number of physicians (1.2; 95% CI 0.6–1.8) and the average Team Climate Inventory score (1.3; 95% CI 0.1–2.5) were modestly associated with high-quality care. Interpretation: We identified a common set of organizational characteristics associated with high-quality primary care. Many of these characteristics are amenable to change through practice-level organizational changes.

When Is Knowledge Ripe for Primary Care? An Exploratory Study on the Meaning of Evidence

The objectives of this study were to explore the meaning of scientific evidence as it is understood by primary care physicians. Individual interviews were conducted with actors chosen for their roles in the production and use of knowledge: 22 family physicians, 13 specialist physicians, and 6 researchers. Two situations served as points of reference for these discussions: screening for genetic breast cancer and treatment of hypertension. The results suggest that there may be a misunderstanding between the producers of knowledge and primary care practitioners with respect to what constitutes “evidence”— knowledge ready for integration into the clinical practice of primary care. These potential differences go beyond the issues of how information is disseminated. Rather, many of the questions raised by family physicians concern how knowledge is developed. In the interests of fostering better dissemination of new knowledge and encouraging its adoption, new links should be created between knowledge “producers” and potential users.

The development of self-efficacy beliefs during general practice vocational training: An exploratory study

Introduction: Retention of general practitioners (GPs) is crucial to ensure appropriate primary care. However, some recently qualified GPs feel unprepared for practice, which may lead them to leave the profession or restrict their scope of practice. The development of self-efficacy beliefs during vocational training may be an important factor in this phenomenon. Methods: Five focus groups with a total of 28 GP trainees and recent graduates were conducted in Belgium and France. Initial analysis using the immersion-crystallisation method was followed by analysis using Banduras self-efficacy framework. Results: Participants described beginning their training with low self-efficacy beliefs. Most participants described how they overcame stressful situations. Some, however, seemed to be developing avoidance strategies. Successfully resolving patient problems, sharing experiences with peers and receiving positive feedback from supervisors, colleagues and patients were conducive to the development of positive self-efficacy beliefs. Discussion: Although low self-efficacy beliefs are natural at the beginning of training, participants seemed to develop in two ways, either overcoming their fears or avoiding them. Identifying the pattern of trainees’ responses to allow tailoring of interventions should be investigated by those who run training programs. Interventions could include reassurance, peer interaction and an appropriate degree of autonomy.

At the interface of community and healthcare systems: a longitudinal cohort study on evolving health and the impact of primary healthcare from the patient's perspectiv

BackgroundMassive efforts in Canada have been made to renew primary healthcare. However, although early evaluations of initiatives and research on certain aspects of the reform are promising, none have examined the link between patient assessments of care and health outcomes or the impacts at a population level. The goal of this project is to examine the effect of patient-centred and effective primary healthcare on the evolution of chronic illness burden and health functioning in a population, and in particularly vulnerable groups: the multi-morbid and the poor.Methods/DesignA randomly selected cohort of 2000 adults aged 25 to 75 years will be recruited within the geographic boundaries of four local healthcare networks in Quebec. At recruitment, cohort members will report on socio-demographic information, functional health and healthcare use. Two weeks, 12 months and 24 months after recruitment, cohort participants will complete a self-administered questionnaire on current health and health behaviours in order to evaluate primary healthcare received in the previous year.The dependent variables are calculated as change over time of functional health status, chronic illness burden, and health behaviours. Dimensions of patient-centred care and clinical processes are measured using sub-scales of validated instruments. We will use Poisson regression modelling to estimate the incidence rate of chronic illness burden scores and structural equation modelling to explore relationships between variables and to examine the impact of dimensions of patient-centred care and effective primary healthcare.DiscussionResults will provide valuable information for primary healthcare clinicians on the course of chronic illness over time and the impact on health outcomes of accessible, patient-centred and effective care. A demonstration of impact will contribute to the promotion of continuous quality improvement activities at a clinical level. While considerable advances have been made in the management of specific chronic illnesses, this will make a unique contribution to effective care for persons with multiple morbidities. Furthermore, the cohort and data architecture will serve as a research platform for future projects.

A process-based framework to guide nurse practitioners integration into primary healthcare teams: results from a logic analysis

BackgroundIntegrating Nurse Practitioners into primary care teams is a process that involves significant challenges. To be successful, nurse practitioner integration into primary care teams requires, among other things, a redefinition of professional boundaries, in particular those of medicine and nursing, a coherent model of inter- and intra- professional collaboration, and team-based work processes that make the best use of the subsidiarity principle. There have been numerous studies on nurse practitioner integration, and the literature provides a comprehensive list of barriers to, and facilitators of, integration. However, this literature is much less prolific in discussing the operational level implications of those barriers and facilitators and in offering practical recommendations.MethodsIn the context of a large-scale research project on the introduction of nurse practitioners in Quebec (Canada) we relied on a logic-analysis approach based, on the one hand on a realist review of the literature and, on the other hand, on qualitative case-studies in 6 primary healthcare teams in rural and urban area of Quebec.ResultsFive core themes that need to be taken into account when integrating nurse practitioners into primary care teams were identified. Those themes are: planning, role definition, practice model, collaboration, and team support.The present paper has two objectives: to present the methods used to develop the themes, and to discuss an integrative model of nurse practitioner integration support centered around these themes.ConclusionIt concludes with a discussion of how this framework contributes to existing knowledge and some ideas for future avenues of study.

Inequities in Medical Follow-Up for Depression: A Population- Based Study in Montreal

OBJECTIVES The aim of this study was to measure the quality of medical follow-up of depression in a universal-access health care system and identify its main correlates. METHODS This retrospective cohort study of adult patients who received diagnoses of depression between April 2003 and March 2005 in Montreal used administrative data to measure the quality of medical follow-up within the first three months of diagnosis. Indicators of adequate follow-up care included having at least one outpatient visit to a family physician or a psychiatrist, the first follow-up visit within 30 days of diagnosis, more than half of follow-up visits with the same physician, and at least three follow-up visits. RESULTS During the study period, 41,375 Montrealers aged 18 and older received a new diagnosis of depression. Among those, 90% (N=37,071) had at least one visit with a physician (family practitioner or psychiatrist) within the first three months of diagnosis, 59% (N=24,295) benefited from continuity with their usual provider, 50% (N=20,846) received a prompt follow-up visit, and 48% (N=19,819) had optimal contacts with practitioners. Medical follow-up was less adequate for older patients, male patients, patients living in very deprived neighborhoods, and patients with high morbidity levels. The quality of medical follow-up was better when both a family physician and a psychiatrist were involved. CONCLUSIONS The results suggest that universal access facilitates optimal practitioner contacts during the acute treatment phase of depression. However, despite universal access, the findings revealed that some inequities persist.