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Regional variation in primary care improvement strategies and policy: case studies that consider qualitative contextual data for performance measurement in three Canadian provinces.

ABSTRACT: OBJECTIVE:To explore regional primary care improvement strategies that are potentially determinants of primary care performance. DESIGN:Multiple comparative embedded case study. SETTING:Three regions in Canada: Fraser East, British Columbia; Eastern Ontario Health Unit, Ontario; Central Zone, Nova Scotia. DATA SOURCES:(1) In-depth interviews with purposively selected key informants (eg, primary care decision-makers, physician leads, regulatory agencies) and focus groups with patients and clinicians (n=68 participants) and (2) published and grey literature (n=205 documents). OUTCOME MEASURES:Variations in spread and uptake of primary care improvement strategies across the three study regions. NVivo (V.11) was used to manage data and perform content analysis to identify categories within and across cases. The coding structure was developed by researchers through iterative collaboration, using inductive and deductive processes. RESULTS:Six overarching primary care improvement strategies, differing in focus and spread, were implemented across the three study regions: interprofessional team-based approaches, provider skill mix expansion, physician groups and networks, information systems, remuneration and performance measurement and reporting infrastructure. CONCLUSION:The addition of information on regional improvement strategies to primary care performance reports could add important contextual insights into primary care performance results. This could help identify possible drivers of reported performance outcomes and levers for change in practice, regional and system-level settings.

SUBMITTER: Martin-Misener R

PROVIDER: S-EPMC6803109 | biostudies-literature | 2019 Oct

REPOSITORIES: biostudies-literature

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Regional variation in primary care improvement strategies and policy: case studies that consider qualitative contextual data for performance measurement in three Canadian provinces.

Martin-Misener Ruth R Wong Sabrina T ST Johnston Sharon S Blackman Stephanie S Scott Catherine C Hogg William W Burge Fred F Grool Anne M AM Campbell John L JL Wuite Sara S

BMJ open 20191017 10

<h4>Objective</h4>To explore regional primary care improvement strategies that are potentially determinants of primary care performance.<h4>Design</h4>Multiple comparative embedded case study.<h4>Setting</h4>Three regions in Canada: Fraser East, British Columbia; Eastern Ontario Health Unit, Ontario; Central Zone, Nova Scotia.<h4>Data sources</h4>(1) In-depth interviews with purposively selected key informants (eg, primary care decision-makers, physician leads, regulatory agencies) and focus gro ...[more]

PMID: 31628125

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Project description:Amidst concerns regarding the capacity of the public health system to respond rapidly and appropriately to threats such as pandemics and terrorism, along with changing population health needs, governments have focused on strengthening public health systems. A key factor in a robust public health system is its workforce. As part of a nationally funded study of public health renewal in Canada, a policy analysis was conducted to compare public health human resources-relevant documents in two Canadian provinces, British Columbia (BC) and Ontario (ON), as they each implement public health renewal activities.A content analysis of policy and planning documents from government and public health-related organizations was conducted by a research team comprised of academics and government decision-makers. Documents published between 2003 and 2011 were accessed (BC?=?27; ON?=?20); documents were either publicly available or internal to government and excerpted with permission. Documentary texts were deductively coded using a coding template developed by the researchers based on key health human resources concepts derived from two national policy documents.Documents in both provinces highlighted the importance of public health human resources planning and policies; this was particularly evident in early post-SARS documents. Key thematic areas of public health human resources identified were: education, training, and competencies; capacity; supply; intersectoral collaboration; leadership; public health planning context; and priority populations. Policy documents in both provinces discussed the importance of an educated, competent public health workforce with the appropriate skills and competencies for the effective and efficient delivery of public health services.This policy analysis identified progressive work on public health human resources policy and planning with early documents providing an inventory of issues to be addressed and later documents providing evidence of beginning policy development and implementation. While many similarities exist between the provinces, the context distinctive to each province has influenced and shaped how they have focused their public health human resources policies.

Project description:BackgroundThe interdependent and intersecting nature of the Sustainable Development Goals (SDGs) require collaboration across government sectors, and it is likely that departments with few past interactions will find themselves engaged in joint missions on SDG projects. Intersectoral action (IA) is becoming a common framework for different sectors to work together. Understanding the factors in the environment external to policy teams enacting IA is crucial for making progress on the SDGs.MethodsInterviews [n=17] with senior public servants leading SDG work in nine departments in the federal government of Canada were conducted to elicit information about issues affecting how departments engage in IA for the SDGs. Transcripts were coded based on a set of factors identified in a background review of 20 documents related to Canada's progress on SDGs. Iterative group thematic analysis by the authors illuminated a set of domestic and global contextual factors affecting IA processes for the SDGs.ResultsThe mechanisms for successful IA were identified as facilitative governance, leadership by a central coordinating office, supportive staff, flexible and clear reporting structures, adequate resources, and targeted skills development focused on collaboration and cross-sector learning. Factors that affect IA positively include alignment of the SDG agenda with domestic and global political priorities, and the co-occurrence of social issues such as Indigenous rights and gender equity that raise awareness of and support for related SDGs. Factors that affect IA negatively include competing conceptual frameworks for approaching shared priorities, lack of capacity for "big picture" thinking among bureaucratic staff, and global disruptions that shift national priorities away from the SDGs.ConclusionIA is becoming a normal way of working on problems that cross otherwise separate government accountabilities. The success of these collaborations can be impacted by contextual factors beyond any one department's control.

Project description:IntroductionImproving health services integration through primary health care (PHC) teams for patients with chronic conditions is essential to address their complex health needs and facilitate better health outcomes. The objective of this study was to explore if and how patients, family members, and caregivers were engaged or wanted to be engaged in developing, implementing and evaluating health policies related to PHC teams. This patient-oriented research was carried out in three provinces across Canada: British Columbia, Alberta and Ontario.MethodsA total of 29 semi-structured interviews with patients were conducted across the three provinces and data were analysed using thematic analysis.ResultsThree key themes were identified: motivation for policy engagement, experiences with policy engagement and barriers to engagement in policy. The majority of participants in the study wanted to be engaged in policy processes and advocate for integrated care through PHC teams. Barriers to patient engagement in policy, such as lack of opportunities for engagement, power imbalances, tokenism, lack of accessibility of engagement opportunities and experiences of racism and discrimination were also identified.ConclusionThis study increases the understanding of patient, family member, and caregiver engagement in policy related to PHC team integration and the barriers that currently exist in this engagement process. This information can be used to guide decision-makers on how to improve the delivery of integrated health services through PHC teams and enhance patient, family member, and caregiver engagement in PHC policy.Patient or public contributionWe would like to acknowledge the contributions of our patient partners, Brenda Jagroop and Judy Birdsell, who assisted with developing and pilot testing the interview guide. Judy Birdsell also assisted with the preparation of this manuscript. This study also engaged patients, family members, and caregivers to share their experiences with engagement in PHC policy.

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Project description:BackgroundMedical errors, unsatisfactory outcomes, or treatment complications often prompt patient complaints about healthcare providers. In response, physicians may adopt defensive practices to mitigate objections, avoid complaints, and navigate lengthy trial processes or other potential threats. However, such defensive medicine (DM) practices can carry risks, including potential harm to patients and the imposition of unnecessary costs on both patients and the healthcare system. Moreover, these practices may run counter to accepted ethical standards in medicine.MethodsThis qualitative study involved conducting semi-structured interviews with 43 physicians, among whom 38 were faculty members at medical universities, 42 had administrative experience at various levels of the health system, and 23 had previously served as health system policymakers. On average, the participants had approximately 23.5 years of clinical experience. The selection of participants was based on purposive sampling. Data collection through interviews continued until data saturation was achieved.ResultsBased on the findings, DM manifests in both positive and negative forms, illustrated by instances like ordering unnecessary lab tests, imaging, or consultations, reluctance to admit high-risk patients, and avoiding high-risk procedures. The study participants identified a range of underlying and contextual factors contributing to DM, encompassing organizational-managerial, social, personal, and factors inherent to the nature of defensive medical practices. The results also highlight proposed strategies to address and prevent DM, which can be grouped into organizational-managerial, social, and those focused on modifying the medical complaints management system.ConclusionDM is a multifaceted and significant phenomenon that necessitates a comprehensive understanding of its various aspects, including interconnected and complex structures and underlying and contextual factors. While the results of this study offer a solid foundation for informing policy decisions within the healthcare system and include some explanatory policy suggestions, we encourage policymakers to complement the findings of this study with other available evidence to address any potential limitations and to gain a more comprehensive understanding of the policymaking process related to DM.

Dataset Information

Regional variation in primary care improvement strategies and policy: case studies that consider qualitative contextual data for performance measurement in three Canadian provinces.

Publications

Regional variation in primary care improvement strategies and policy: case studies that consider qualitative contextual data for performance measurement in three Canadian provinces.

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