Nassera Touati

Accreditation at a crossroads: Are we on the right track?

OBJECTIVES By comparing Canada, where accreditation is optional, to France, where it is required, this study evaluates the extent to which the accreditation process acts as a tool for bureaucratic coercion as opposed to a tool for learning. METHODS Our study consists of a qualitative meta-analysis of studies of French and Canadian accreditation experiences between 1996 and 2006. Using the conceptual framework of Adler and Borys [Adler P, Borys B. Two types of bureaucracy: enabling and coercitive. Administration Science Quarterly 1996;41:61-89], we assess the characteristics of accreditation in the French and the Canadian environments and distinguish between coercive and enabling modi operandi. RESULTS Results show that accreditation has positive impacts in the two countries but is more coercion-oriented in France than in Canada. This is because in France: (1) the fact that accreditation is compulsory and certain standards are required by law limits participants opportunities to influence the process; (2) standards are not adapted to various clinical programs and as a result, participants contest their legitimacy; (3) ambiguity about the use of accreditation visit results has sullied global transparency. Despite differences between the French and Canadian systems, however, both systems are converging towards a mixed model that includes elements of both philosophies, with the Canadian model becoming more coercive and the French model becoming more flexible and learning-oriented. CONCLUSION Comparison of the two cases shows that current trends in the evolution of accreditation threaten the very purpose of the accreditation process.

Evaluation of the impact of interdisciplinarity in cancer care

BackgroundTeamwork is a key component of the health care renewal strategy emphasized in Quebec, elsewhere in Canada and in other countries to enhance the quality of oncology services. While this innovation would appear beneficial in theory, empirical evidences of its impact are limited. Current efforts in Quebec to encourage the development of local interdisciplinary teams in all hospitals offer a unique opportunity to assess the anticipated benefits. These teams working in hospital outpatient clinics are responsible for treatment, follow-up and patient support. The study objective is to assess the impact of interdisciplinarity on cancer patients and health professionals.Methods/DesignThis is a quasi-experimental study with three comparison groups distinguished by intensity of interdisciplinarity: strong, moderate and weak. The study will use a random sample of 12 local teams in Quebec, stratified by intensity of interdisciplinarity. The instrument to measure the intensity of the interdisciplinarity, developed in collaboration with experts, encompasses five dimensions referring to aspects of team structure and process. Self-administered questionnaires will be used to measure the impact of interdisciplinarity on patients (health care utilization, continuity of care and cancer services responsiveness) and on professionals (professional well-being, assessment of teamwork and perception of teamwork climate). Approximately 100 health professionals working on the selected teams and 2000 patients will be recruited. Statistical analyses will include descriptive statistics and comparative analysis of the impact observed according to the strata of interdisciplinarity. Fixed and random multivariate statistical models (multilevel analyses) will also be used.DiscussionThis study will pinpoint to what extent interdisciplinarity is linked to quality of care and meets the complex and varied needs of cancer patients. It will ascertain to what extent interdisciplinary teamwork facilitated the work of professionals. Such findings are important given the growing prevalence of cancer and the importance of attracting and retaining health professionals to work with cancer patients.

Assessing the performance of centralized waiting lists for patients without a regular family physician using clinical-administrative data

BackgroundWith 4.6 million patients who do not have a regular family physician, Canada performs poorly compared to other OECD countries in terms of attachment to a family physician. To address this issue, several provinces have implemented centralized waiting lists to coordinate supply and demand for attachment to a family physician. Although significant resources are invested in these centralized waiting lists, no studies have measured their performance. In this article, we present a performance assessment of centralized waiting lists for unattached patients implemented in Quebec, Canada.MethodsWe based our approach on the Balanced Scorecard method. A committee of decision-makers, managers, healthcare professionals, and researchers selected five indicators for the performance assessment of centralized waiting lists, including both process and outcome indicators. We analyzed and compared clinical-administrative data from 86 centralized waiting lists (GACOs) located in 14 regions in Quebec, from April 1, 2013, to March 31, 2014.ResultsDuring the study period, although over 150,000 patients were attached to a family physician, new requests resulted in a 30% median increase in patients on waiting lists. An inverse correlation of average strength was found between the rates of patients attached to a family physician and the proportion of vulnerable patients attached to a family physician meaning that as more patients became attached to an FP through GACOs, the proportion of vulnerable patients became smaller (r = −0.31, p < 0.005). The results showed very large performance variations both among GACOs of different regions and among those of a same region for all performance indicators.ConclusionsCentralized waiting lists for unattached patients in Quebec seem to be achieving their twofold objective of attaching patients to a family physician and giving priority to vulnerable patients. However, the demand for attachment seems to exceed the supply and there appears to be a tension between giving priority to vulnerable patients and attaching of a large number of patients. Results also showed heterogeneity in the performance of centralized waiting lists across Quebec. Finally, our findings suggest it is critical that similar mechanisms should use available data to identify the best strategies for reducing variations and improving performance.

Développement et application d’une vignette clinique pour apprécier la qualité des soins en oncology

Position du probleme Dans le cadre d’une etude portant sur le deploiement et les effets d’un reseau de soins integres pour la clientele atteinte d’un cancer de la Monteregie (Quebec), la strategie de recherche de la vignette a ete retenue afin d’apprecier la qualite des soins d’equipes interdisciplinaires œuvrant aupres de cette clientele. Cette strategie de recherche est depuis peu utilisee pour apprecier les pratiques professionnelles. Dans cet article, un angle resolument methodologique a ete pris afin de rendre compte d’une experience rigoureuse, novatrice et transferable quant a l’elaboration d’une vignette. Methodes Une demarche, comptant six etapes, a ete adoptee pour l’elaboration de la vignette. Celle-ci comprend une collaboration avec des cliniciens. Cette demarche nous assure de l’atteinte d’une validite de contenu elevee en fonction des aspects de sa pertinence, de son exhaustivite et de sa comprehensibilite aupres des repondants. Notre vignette clinique decrit une sequence d’evenements associes a la prise en charge typique d’un homme de 58 ans atteint d’un cancer du rectum. La collecte de donnees a pris la forme d’entretiens de groupe aupres des equipes interdisciplinaires (n = 5) etudiees. Les professionnels presents ont ete invites a decrire leurs pratiques usuelles face aux evenements decrits dans la vignette. Deux strategies d’analyse de donnees ont ete retenues : une comparaison des pratiques revelees a partir des entretiens a un scenario de reponses attendues en fonction des orientations du Programme quebecois de lutte contre le cancer et, d’autre part, une analyse en fonction de dimensions de la qualite des soins. Resultats Les pratiques professionnelles des equipes semblent evoluer vers une offre de soins que valorise le Programme quebecois de lutte contre le cancer. Des differences ont egalement ete observees entre les equipes quant a la continuite des soins. Conclusion Notre etude montre qu’il est possible de developper une vignette permettant de saisir les pratiques professionnelles en contexte d’interdisciplinarite pourvu qu’une demarche rigoureuse soit adoptee. Cette demarche, transferable a l’etude de phenomenes similaires, permet de documenter l’offre de soins et de contribuer au renouvellement des pratiques professionnelles.

Conditions for production of interdisciplinary teamwork outcomes in oncology teams: protocol for a realist evaluation

BackgroundInterdisciplinary teamwork (ITW) is designed to promote the active participation of several disciplines in delivering comprehensive cancer care to patients. ITW provides mechanisms to support continuous communication among care providers, optimize professionals’ participation in clinical decision-making within and across disciplines, and foster care coordination along the cancer trajectory. However, ITW mechanisms are not activated optimally by all teams, resulting in a gap between desired outcomes of ITW and actual outcomes observed. The aim of the present study is to identify the conditions underlying outcome production by ITW in local oncology teams.MethodsThis retrospective multiple case study will draw upon realist evaluation principles to explore associations among context, mechanisms and outcomes (CMO). The cases are nine interdisciplinary cancer teams that participated in a previous study evaluating ITW outcomes. Qualitative data sources will be used to construct a picture of CMO associations in each case. For data collection, reflexive focus groups will be held to capture patients’ and professionals’ perspectives on ITW, using the guiding question, ‘What works, for whom, and under what circumstances?’ Intra-case analysis will be used to trace associations between context, ITW mechanisms, and patient outcomes. Inter-case analysis will be used to compare the different cases’ CMO associations for a better understanding of the phenomenon under study.DiscussionThis multiple case study will use realist evaluation principles to draw lessons about how certain contexts are more or less likely to produce particular outcomes. The results will make it possible to target more specifically the actions required to optimize structures and to activate the best mechanisms to meet the needs of cancer patients. This project could also contribute significantly to the development of improved research methods for conducting realist evaluations of complex healthcare interventions. To our knowledge, this study is the first to use CMO associations to improved empirical and theoretical understanding of interdisciplinary teamwork in oncology, and its results could foster more effective implementation in clinical practice.

Evaluating Service Organization Models The Relevance and Methodological Challenges of a Configurational Approach

Based on the example of the evaluation of service organization models, this article shows how a configurational approach overcomes the limits of traditional methods which for the most part have studied the individual components of various models considered independently of one another. These traditional methods have led to results (observed effects) that are difficult to interpret. The configurational approach, in contrast, is based on the hypothesis that effects are associated with a set of internally coherent model features that form various configurations. These configurations, like their effects, are context-dependent. We explore the theoretical basis of the configuration approach in order to emphasize its relevance, and discuss the methodological challenges inherent in the application of this approach through an in-depth analysis of the scientific literature. We also propose methodological solutions to these challenges. We illustrate from an example how a configurational approach has been used to evaluate primary care models. Finally, we begin a discussion on the implications of this new evaluation approach for the scientific and decision-making communities.

Learning in Health Care Organizations and Systems: An Alternative Approach to Knowledge Management

This article presents, through the example of health care systems, a theoretically founded analysis of learning processes in the context of reform implementation. Following a critical assessment of the two most prominent approaches to knowledge management—mechanistic and organic—we propose another approach, which consists in coordinating the learning of interdependent actors. The potential of this approach is illustrated through an empirical case study of the implementation of a Quebec program to combat cancer.

What Are the Factors Influencing Implementation of Advanced Access in Family Medicine Units? A Cross-Case Comparison of Four Early Adopters in Quebec

Introduction Advanced access is an organizational model that has shown promise in improving timely access to primary care. In Quebec, it has recently been introduced in several family medicine units (FMUs) with a teaching mission. The objectives of this paper are to analyze the principles of advanced access implemented in FMUs and to identify which factors influenced their implementation. Methods A multiple case study of four purposefully selected FMUs was conducted. Data included document analysis and 40 semistructured interviews with health professionals and staff. Cross-case comparison and thematic analysis were performed. Results Three out of four FMUs implemented the key principles of advanced access at various levels. One scheduling pattern was observed: 90% of open appointment slots over three- to four-week periods and 10% of prebooked appointments. Structural and organizational factors facilitated the implementation: training of staff to support change, collective leadership, and openness to change. Conversely, family physicians practicing in multiple clinical settings, lack of team resources, turnover of clerical staff, rotation of medical residents, and management capacity were reported as major barriers to implementing the model. Conclusion Our results call for multilevel implementation strategies to improve the design of the advanced access model in academic teaching settings.

Effects of interdisciplinary teamwork on patient-reported experience of cancer care

BackgroundInterdisciplinary teamwork (ITW) is deemed necessary for quality cancer care practices. Nevertheless, variation in ITW intensity among cancer teams is understudied, and quantitative evidence of the effect of different ITW intensities among cancer teams on patients’ perceived experience of care is limited. This study aims to compare patient-reported experience measures (PREMs) of cancer outpatients followed by teams characterized by high vs. low ITW intensity.MethodsThe study is designed as an ex post facto quasi-experimental study. Participants (n = 1379) were recruited in nine outpatient oncology clinics characterized by different ITW intensities. ITW intensities were evaluated using the characteristics of structure (team composition and size) and process (interactions among team members), as per West’s seminal work on team effectiveness. ITW intensity was dichotomized (high vs. low ITW intensity). PREMs were classified and measured using validated scales corresponding to six dimensions: Prompt access to care, Person-centred response, Quality of patient-professional communication, Quality of the care environment, Continuity of care, and Results of care. Dichotomous variables were created for each dimension (positive vs. less positive experience). Multiple logistic regression analyses were performed to assess the association between ITW intensities and the six PREMs dimensions, while controlling for patient and organizational characteristics. PROC GENMOD was used to fit logistic models for categorical variables.ResultsOutpatients treated by teams characterized by high ITW intensity reported almost four times more positive perceptions of Prompt access to care compared to patients treated by low ITW intensity teams (OR = 3.99; CI = 1.89–8.41). High ITW intensity also positively affected patients’ perceptions of Quality of patient-professional communication (OR = 2.37; CI = 1.25–4.51), Person-centred response (OR = 2.11; CI = 1.05–4.24], and Continuity of care (OR = 2.18; CI = 1.07–4.45). No significant association was found between ITW intensity and perceived Results of care (OR = 1.31; CI = 0.68–2.52) or Quality of the care environment (OR = 0.66; CI = 0.31–1.39).ConclusionsThis study provides empirical evidence, from the patient’s perspective, that ITW intensity affects some critical aspects of patient-reported quality of care. Future research will allow explaining how and why ITW structure and processes may contribute to positive cancer care experiences.

Care access in rural areas: what leverage mechanisms do regulatory agencies have in a public system?

Abstract: Based on observations of the governments vital role in enhancing rural health care accessibility, in this article, we analyze solutions implemented by Quebecs public health system by highlighting the limitations in incentives used to remedy the dearth of rural medical resources and the consequent interest in ameliorating health care accessibility through service integration. The current challenge lies in fostering cooperation between health care institutions not subject to market incentives and integrating private practice physicians into the public system. To this end, regulatory agencies in public systems use four main leverage mechanisms: formal power, economic power, influence, and commitment, as illustrated in an experiment conducted in rural Quebec.