Accountability by Design: Moving Primary Care Reform Ahead in Alberta

Health-care reform is perennially popular in Alberta, but reality doesn’t match the rhetoric. Government has invested more than $700 million in Primary Care Networks — with little beyond anecdotal evidence of the value achieved with this investment. As the province redirects primary care to Family Care Clinics, the authors assert that simply tinkering with one part of the system is not the answer: health care must change on a system-wide basis. Drawing on the experiences of frontline staff and a rich body of literature, the authors present their vision for integrated team-based primary care, designed to be accountable to meet the needs of populations. This will require governance that makes primary care the hub of the system, and brings together government and health-services leadership to support the integration of primary and specialty care. There are shared accountabilities for achieving primary care that exhibits the attributes of high performing primary care systems, and these exist at multiple levels, from individuals seeking primary care, up to and including government. The authors make these accountabilities explicit, and outline strategies to secure their achievement that include system redesign, service delivery redesign and payment reform. All of this demands whole-system reform focused on primary care, and it won’t be easy. There are plenty of vested interests at stake, and a truly transformative vision requires buy-in at every level. However, Alberta’s rapidly growing and aging population makes it more urgent than ever to realize such a vision. This paper offers guidelines to spark the fresh thinking required

Online reflections : a constructivist tool?

vii, 74 leaves ; 29 cm. --The purpose of this study was to determine whether or not online reflections are effective in facilitating student learning, as measured by achievement on unit exams and instructional planning as reported by the instructor. This study followed an altematingtreatments design. The achievement of 22 students randomly divided into two groups of 11 students each (Group 1 and Group 2) was compared. The first group of students followed an A-B-A-B design and the second group of students from the same Biology class followed a B-A-B-A design. A refers to the condition where students completed higher order online reflections and B refers to the lower order word search condition. The word search condition in this study serves as a proxy control condition in this study. Achievement on unit exams was determined and compared for each student under treatment condition A and treatment condition B. Correlations between the average length of students' responses, the number of reflections and word searches completed and students' final marks were conducted to identify the degree of association between these variables. 5-10 minutes of class time was provided to students to complete their online reflections or word searches. Analysis of variance was used to compare the effect completing online reflections and word searches had on student achievement as measured by unit-exams marks. No significant differences in achievement were found between the two conditions. The number and average length of online reflections were positively and significantly correlated with a student's final mark (Pearson correlation = 0.556, .Q = 0.007; 0.463, .Q = 0.03). 50% (10/20) of students felt that online reflections helped them study. 45% (9/20) felt that they clarified their understanding of scientific concepts. Students identified the following benefits of online reflections: it helps you remember, improves understanding and helps you think. The most common suggestion made by students for improvement was to change the questions with each lesson so that they were more relevant. The instructor felt the questions asked by students in the online reflections were important as they provided insight into what students know and don't know. As a result of online reflections the instructor now incorporates regular and in depth reviews into his teaching. According to the instructor online reflections helped him and his class meet 8 technology outcomes (i.e. Students will compose, revise and edit text). Future studies should control for the Hawthorne effect by changing the reflection questions on a daily basis and control for the different academic abilities of students

Interprofessional teamwork innovations for primary health care practices and practitioners: evidence from a comparison of reform in three countries

Context: A key aim of reforms to primary health care (PHC) in many countries has been to enhance interprofessional teamwork. However, the impact of these changes on practitioners has not been well understood.Objective: To assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in PHC practices.Design: Collaborative synthesis of 12 mixed methods studies.Setting: Primary care practices undergoing transformational change in three countries: Australia, Canada, and the USA, including three Canadian provinces (Alberta, Ontario, and Quebec).Methods: We conducted a synthesis and secondary analysis of 12 qualitative and quantitative studies conducted by the authors in order to understand the impacts and how they were influenced by local context.Results: There was a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions. These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups.Conclusion: The variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level. The same characteristic could have both positive and negative influence on different aspects (eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice). Thus, the impacts are not entirely predictable and need to be monitored, and so that interventions can be adapted at the local level

Dimensions and intensity of inter-professional teamwork in primary care: Evidence from five international jurisdictions

Background. Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients' needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated. Objective. The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams. Methods. Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with faceto- face group retreats, using a Collaborative Reflexive Deliberative Approach. Results. Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team's production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team's activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts. Conclusion. The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes

Dimensions and intensity of inter-professional teamwork in primary care: evidence from five international jurisdictions

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Uncovering the wisdom hidden between the lines:the Collaborative Reflexive Deliberative Approach

Background: Meta-analysis and meta-synthesis have been developed to synthesize results across published studies; however, they are still largely grounded in what is already published, missing the tacit \u27between the lines\u27 knowledge generated during many research projects that are not intrinsic to the main objectives of studies. Objective: To develop a novel approach to expand and deepen meta-syntheses using researchers\u27 experience, tacit knowledge and relevant unpublished materials. Methods: We established new collaborations among primary health care researchers from different contexts based on common interests in reforming primary care service delivery and a diversity of perspectives. Over 2 years, the team met face-to-face and via tele- and video-conferences to employ the Collaborative Reflexive Deliberative Approach (CRDA) to discuss and reflect on published and unpublished results from participants\u27 studies to identify new patterns and insights. Results: CRDA focuses on uncovering critical insights, interpretations hidden within multiple research contexts. For the process to work, careful attention must be paid to ensure sufficient diversity among participants while also having people who are able to collaborate effectively. Ensuring there are enough studies for contextual variation also matters. It is necessary to balance rigorous facilitation techniques with the creation of safe space for diverse contributions. Conclusions: The CRDA requires large commitments of investigator time, the expense of convening facilitated retreats, considerable coordination, and strong leadership. The process creates an environment where interactions among diverse participants can illuminate hidden information within the contexts of studies, effectively enhancing theory development and generating new research questions and strategies

Contextual levers for team-based primary care: lessons from reform interventions in five jurisdictions in three countries

Background: Most Western nations have sought primary care (PC) reform due to the rising costs of health care and the need to manage long-term health conditions. A common reform-the introduction of inter-professional teams into traditional PC settings-has been difficult to implement despite financial investment and enthusiasm. Objective: To synthesize findings across five jurisdictions in three countries to identify common contextual factors influencing the successful implementation of teamwork within PC practices. Methods: An international consortium of researchers met via teleconference and regular face-to-face meetings using a Collaborative Reflexive Deliberative Approach to re-analyse and synthesize their published and unpublished data and their own work experience. Studies were evaluated through reflection and facilitated discussion to identify factors associated with successful teamwork implementation. Matrices were used to summarize interpretations from the studies. Results: Seven common levers influence a jurisdiction\u27s ability to implement PC teams. Team-based PC was promoted when funding extended beyond fee-for-service, where care delivery did not require direct physician involvement and where governance was inclusive of non-physician disciplines. Other external drivers included: the health professional organizations\u27 attitude towards team-oriented PC, the degree of external accountability required of practices, and the extent of their links with the community and medical neighbourhood. Programs involving outreach facilitation, leadership training and financial support for team activities had some effect. Conclusion: The combination of physician dominance and physician aligned fee-for-service payment structures provide a profound barrier to implement team-oriented PC. Policy makers should carefully consider the influence of these and our other identified drivers when implementing team-oriented PC

Dimensions and intensity of inter-professional teamwork in primary care: evidence from five international jurisdictions.

Background: Inter-professional teamwork in primary care settings offers potential benefits for responding to the increasing complexity of patients\u27 needs. While it is a central element in many reforms to primary care delivery, implementing inter-professional teamwork has proven to be more challenging than anticipated. Objective: The objective of this study was to better understand the dimensions and intensity of teamwork and the developmental process involved in creating fully integrated teams. Methods: Secondary analyses of qualitative and quantitative data from completed studies conducted in Australia, Canada and USA. Case studies and matrices were used, along with face-to-face group retreats, using a Collaborative Reflexive Deliberative Approach. Results: Four dimensions of teamwork were identified. The structural dimension relates to human resources and mechanisms implemented to create the foundations for teamwork. The operational dimension relates to the activities and programs conducted as part of the team\u27s production of services. The relational dimension relates to the relationships and interactions occurring in the team. Finally, the functional dimension relates to definitions of roles and responsibilities aimed at coordinating the team\u27s activities as well as to the shared vision, objectives and developmental activities aimed at ensuring the long-term cohesion of the team. There was a high degree of variation in the way the dimensions were addressed by reforms across the national contexts. Conclusion: The framework enables a clearer understanding of the incremental and iterative aspects that relate to higher achievement of teamwork. Future reforms of primary care need to address higher-level dimensions of teamwork to achieve its expected outcomes