Improving Primary Health Care Through Collaboration: Briefing 2 ...

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For the exclusive use of Mona Lesage, mlesage@wrha.mb.ca, Winnipeg Regional Health Authority.4 | Improving Primary Health Care Through Collaboration: Briefing 2—October 2012collaboration within the family health team, for somestudy participants “language use, in addition to communicationskill, continued to reflect and reinforce theperceived importance and centrality of physicians byother team members, despite deliberate efforts on thepart of physicians to create and participate in a collaborativeenvironment.” 20 They found that the hierarchicalroles that remained, even after two years of implementingthe intervention, were probably a result of historicalrelationships—particularly between physicians andnurses—that were still deeply embedded in the cultureof the practice. This hierarchical relationship continuedto impact how team members perceived each other andtheir role on the team. Whether this hierarchical structure,either real or perceived, should or could be eliminatedis uncertain. Nevertheless, factors that perpetuate hierarchy,such as language and decision-making processes,could be modified in order to reduce their potentialnegative impact on interprofessional collaboration.Practice-Level Barriers toInterprofessional CollaborationThis section will examine the factors at the practicelevel that pose barriers to IPC team optimization. Thesebarriers include lack of strong governance structure andleadership to manage complex practices; difficulties inestablishing appropriate skill mix and team size; insufficientspace and time for communication and collaboration;and inadequate communication mechanisms and tools.These involved the inclusion and expanded roles ofother health professionals and administrative staff, newgovernance and leadership structures, integrated qualityimprovement processes, electronic medical record systems,etc. The lack of strong governance and leadershipstructures and the capacity to manage these complexpractices can be a significant barrier to optimizingthe IPC team.This section of the briefing examines the factors at thepractice level that pose barriers to interprofessionalprimary care team optimization.Governance involves structures, policies, and proceduresthat ensure an organization’s value to the people whofund it and who expect to receive quality care from theorganization. 22 Governing bodies are responsible forplanning, resource allocation, performance monitoring,and accountability. The majority of community healthcentres, family health teams, and nurse practitioner-ledclinics are governed by a board that is represented byprovider groups and/or community members. 23 Not allgoverning boards are the same, and some are betterequipped than others to manage the challenges faced bycomplex IPC teams. According to Bateman, Bailey, andMcLellan, the complex primary care team practicesrequire effective supports to help management, clericalstaff, and health providers address the inevitable difficultiesthe team will experience. 24Lack of Strong Governance Structure andLeadership to Manage Complex PracticesAs previously mentioned, there have been significantreforms in primary care over the past decade, which hasresulted in the rapid advent and evolution of IPC teams.Unfortunately, many of these teams have been ill equippedto develop, implement, and adapt to these transformativechanges. 21 A number of the current IPC teams have faceddifficulties in sustaining transformative change. Many ofthe newer IPC teams in Canada evolved from fee-forservice,physician-led practices to complex practices.20 Gotlib Conn and others, “Creating Sustainable Change inthe Interprofessional Academic Family Practice Setting.”21 Ibid.Clinical and/or team leader physicians and nurses arechallenged to recreate themselves as facilitators of collaboration,in which they often have little or no trainingor experience. 25 As a result, lack of leadership in managingand facilitating collaboration and team operationscan be a significant barrier. Some IPC team modelshave established leadership teams that include a president/corporateexecutive board/executive director, team22 Working Group on Primary Care Governance and Organization,Strengthening Primary Care Organization & Governance.23 Ibid.24 Bateman, Bailey, and McLellan, “Of Rocks and Safe Channels.”25 Howard and others, “Physicians as Inclusive Leaders.”Find this briefing and other Conference Board research at www.e-library.ca
© The Conference Board of Canada. All rights reserved. Please contact cboc.ca/ip with questions or concerns about the use of this material.The Conference Board of Canada | 5directors, coordinators, clinical and administrative leads,and administrative assistants who act as the interfacebetween the body to which the IPC team is accountable(e.g., governing board, regional health authority, Ministryof Health, etc.) and the IPC team. 26 These leadershipteams play a role in establishing a strategic direction,policies, guidelines, and terms of reference that guidethe operations of the IPC team. According to a recentstudy by Drummond and others, there is “no study thatclearly examines the role and effect of clinic organizationalleadership and managerial decision-making on theimplementation and development of interprofessionalpractice.” This suggests that a lack of strong organizationalleadership is an underestimated barrier to theimplementation of effective IPC teams. 27Difficulties in Establishing AppropriateSkill Mix and Team SizeOne of the challenges for IPC team managers is decidingwhich types of and how many health professionals areappropriate for the team. A systematic review by Tiemanand others observed that the more disciplines and servicesincluded in integrated, coordinated, and multidisciplinarycare, the greater the improvement in patient outcomes. 28However, health human resources adequacy is difficultto assess because it relates to other factors, includingpatient needs and preferences, the availability of personnel,cost, and quality. 29Skill MixThere is no one-size-fits-all model in terms of appropriatestaff mix. Staff mix is highly reliant on the professionalcompetencies or skills and experience required to addressthe health needs of the patient population. For example,smoking cessation programs may be managed by nursepractitioners, registered nurses, or pharmacists. Theseconsiderations are related to the issues around managingand optimizing professional scopes of practice discussedearlier in this briefing. The current discussions about26 Dinh, Improving Primary Health Care Through Collaboration.Briefing 1.27 Drummond and others, “Interprofessional Primary Care inAcademic Family Medicine Clinics.”28 Tieman and others, “Integration, Coordination andMultidisciplinary Care.”29 Dubois and Singh, “From Staff-Mix to Skill-Mix and Beyond.”primary care reform have placed increased emphasison a “whole system” approach to caring for patientsthat takes into account the need to involve other nonclinicalstaff on teams, such as human resources fromdisciplines like social services and community workers. 30Clerical staff are also an essential part of the team, as theydeal with scheduling, oversee clinic operations, ensuredata collection and reporting of patient information,conduct telephone follow-up with patients, and performother administrative tasks crucial to the effectiveness ofthe team. 31 Inadequate approaches to human resourcesmanagement in primary care may result in the overuse,underuse, or misuse of existing health personnel. 32Canadian data on the health and economic impacts oftask substitution and supplementation between physiciansand other health professionals are sparse, whichadds to the challenge of identifying appropriate staffor skill mix.Team SizeThere is a gap in knowledge regarding the optimal sizeof the IPC team. Smaller team sizes may reduce accessibility,continuity, and quality of care, thus shifting theburden to other parts of the health care system (e.g., theacute care system). 33 On the other hand, more is notnecessarily better: too many team members can reduceeffectiveness. 34 The appropriate number of primary carephysicians depends on the size and health needs of theserviced population, the number of hours the physicianworks, the number and roles of non-physician providers,and the funds available. 35 Some research exists on theoptimal number of patients under the care of a full-timeequivalent physician (optimal panel size). 36 However,several contextual factors influence appropriate size,including patient population characteristics, place of30 Sommers and others, “Physician, Nurse, and Social WorkerCollaboration in Primary Care for Chronically Ill Seniors.”31 Gotlib Conn and others, “Creating Sustainable Change in theInterprofessional Academic Family Practice Setting.”32 Dubois and Singh, “From Staff-Mix to Skill-Mix and Beyond.”33 Muldoon and others, “How Many Patients Should a FamilyPhysician Have?”34 Cohen and Bailey, “What Makes Teams Work.”35 Muldoon and others, “How Many Patients Should a FamilyPhysician Have?”36 Ibid.Find this briefing and other Conference Board research at www.e-library.ca
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