Background
Methods
Setting and context
Intervention
Data collection
Analysis
Results
FHT characteristics | ||||
Total | Recruited | Not Interviewed | Interviewed | |
Sample Size | 118 | 45 | 101 | 171
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Mean (SD) | Mean (SD) | Mean (SD) | Mean (SD) | |
Roster Size | 20,788 (32,419.3) | 19,417 (17,383.3) | 20,994 (34,644.8) | 19,622 (15,126.5) |
SAMI | 0.99 (0.1) | 0.99 (0.1) | 0.99 (0.1) | 1.00 (0.1) |
% (n) | % (n) | % (n) | % (n) | |
Setting | ||||
Rural | 47 (56) | 42 (19) | 50 (51) | 29 (5) |
Urban | 53 (62) | 58 (26) | 50 (50) | 71 (12) |
Hosp. Discharge Data | 61 (72) | 69 (31) | 59 (60) | 71 (12) |
Teaching Status | ||||
Academic | 17 (20) | 9 (4) | 18 (18) | 12 (2) |
Non-Teaching | 26 (31) | 33 (15) | 24 (24) | 41 (7) |
Teaching | 57 (67) | 58 (26) | 58 (59) | 47 (8) |
Interview Formats | ||||
1-on-1% (n) | 2-on-1% (n) | 3-on-1% (n) | Total % (n) | |
By Practice | 66.7 (12) | 27.8 (5) | 5.6 (1) | 100 (18) |
Participant Type | ||||
ED2
| 71.4 (10) | 21.4 (3) | 7.1 (1) | 100 (14) |
MD3
| 0.0 (0) | 66.7 (2) | 33.3 (1) | 100 (3) |
QIDSS4
| 25.0 (1) | 50.0 (2) | 25.0 (1) | 100 (4) |
IHP5
| 0.0 (0) | 100 (1) | 0.0 (0) | 100 (1) |
Other | 33.3 (1) | 66.7 (2) | 0.0 (0) | 100 (3) |
Total | 48.0 (12) | 40.0 (10) | 12.0 (3) | 100 (25) |
Theme | Summary |
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Outer Setting | |
Policy Advocacy | D2D was identified as a vehicle to support two policy priorities: 1) The future direction of Primary Care quality improvement and performance measurement; and 2) The value and contribution of FHTs to Ontario’s Health Care System. |
“We wanted to be able to work with AFHTO to start being able to direct where Health Quality Ontario was asking us to go on our quality improvement by using data that was more accurate or more up to date, to create those conversations…” (ID = 015)
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Peer Influence | Knowledge of peer participation in D2D facilitated participation in a minority of cases. |
“Other people participating doesn’t really drive our D2D work…”(ID = 018)
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Good Soldier Phenomenon | Observed in two ways: 1) Some informants had external responsibilities to AFHTO. Participation in D2D was part of their efforts to support AFHTO initiatives. 2) Some FHTs agreed to participate to fulfill their responsibility as a member of AFHTO. |
“…we participate, really to be good corporate citizens.” (ID = 001)
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Inner Setting | |
Availability of Implementation Leader | A dedicated staff person to support implementation was seen as essential component for participation. Without this resource, most practices interviewed would not participate. |
“…our [QIDSS] really kind of pushed it too, and he was there to help us get the information. That made it a bit easier.” (ID = 015)
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Development of QI Capacity | D2D was viewed as a means to improve teams’ development of quality improvement capacity. |
“We wanted to be able to measure how we’re doing, to be able to compare ourselves with similar groups throughout the province, but knowing that, for us, we were just starting the measurement process. And we wanted to know what we’re able to do and what our limitations were.” (ID = 012)
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Intervention Characteristics | |
Promise of Future Potential | Participation was influenced by a promise of a “best-in-class” data tool which will be developed by ongoing participation. Desirable features included: Peer comparison and Benchmarking, the use of up to date data, the consolidation of data from a variety of sources and that the tool would be directly informed by participant feedback. |
“…I think that need is right now mostly based on a promise. The promise is what is going to happen with future iterations, and that its going to continue to develop until it actually is a robust, useful, accessible, meaningful exercise. I think we’ve taken initial steps towards that, but we need it to continue in that area” (ID = 014)
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Evidence Base
| No FHTs considered an evidence base in deciding to participate in D2D. |
“I don’t think I have to go to my IT expert and say, do you think measuring how we’re doing is a good idea? It just kind of is. I don’t know how else to say it. I never presented to the group what was the evidence base behind D2D. To me…this is good for QI, this is good for accountability…” (ID = 017)
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Outer setting
Policy advocacy
• AFHTO has been very engaged and very involved. They have pushed because they knew there was a gap there. And they solved that for our organization, so they need … That involved from AFHTO is really, really important. Even if this is something that is taken over by the ministry, I think having them involved as speaking on behalf of the family health teams is really, really important. (ID = 012) |
• Getting back to what I was saying before, I’d rather be leading the way than told what to do and how to do it. So I see D2D as our opportunity to really put it out there and say look, to the government, if you’re going to try to measure how well we’re doing and the quality of our healthcare, I’d rather be the one saying this is a known shown evidence-based way to do it. I think we’re working on that with D2D. (ID = 014) |
• I need a need for D2D, I think it depends on what the raison d’etre of D2D is. My understanding, perhaps incorrect, initially, was that it was clear that there was going to be reporting mechanisms being put in place, being forced upon us from the ministry, and that AFHTO wanted to try to get in on the ground floor to try to see … basically to influence the ministry. What’s feasible, what’s reasonable, what’s important to primary care, and to get clinicians involved in trying to influence those decisions. I think from that respect, D2D is important. (ID = 001) |
• The other part of it was we wanted to be able to work with AFHTO to start being able to direct where Health Quality Ontario was asking us to go on our quality improvement by using data that was more accurate or more up to date, to create those conversations between AFHTO and HQO. (ID = 015) |
• Well, I think it puts us in a good position if indicators that we report on D2D are ones expected of us, say from the Ministry. I think that puts us in a great position because we’re already able to report on them. (ID = 006) |
• Knowing that we were in a climate where primary care, just in general, was being scrutinized around performance and whether or not it was actually making an impact, patient-centred and outcomes and things like that. It was always, from the get-go, probably, the underlying reason why we wanted to participate in the day-to-day because we wanted to tell the story. Yes, don’t believe everything you are hearing out there. At the local level, we are making a lot of really good progress around patient outcomes. (ID = 003) |
• So sometimes perhaps the Ministry will be looking for information that doesn’t paint the true picture of what primary care, the members of AFHTO are doing. So by having the association work with us to generate these measurement reports, we can actually give them to the Ministry at different levels of how that goes and share the information and say this is where we’re doing very well, this is where we’re making a difference. You may not be aware of that based on what you’re looking to collect yourselves. So that’s my thought on it. (ID = 019) |
• I know there’s been a lot of question regarding the impact the family health teams have had. It was a rather expensive rollout for the government to establish all the teams, and they’ve obviously put a pause on the expansion of those teams over the last year or so, they’ve slowed down quite a bit, actually. (ID = 021) |
• I would argue that people didn’t view this so much as a policy climate as they viewed it as a political climate where the Ministry was trying to justify the huge price tag of family health teams. And being able to demonstrate a high level of performance impact on the health care system, which I understand, I think that was fine. I think, initially, people viewed this is an overwhelming experience. (ID = 005) |
Peer influence
• I think we took the plunge regardless early in the first reiteration of D2D because we just thought it was the right thing to do. We didn’t really know what would come out of it exactly so I don’t know how much influence knowing others were participating, but we thought it was safe enough for us to, as I would say, dip your big toe in, see what came back, and how many teams participated. I believe in early days it wasn’t a lot of teams, but I think other teams were convinced to join after the fact when we were able to share some of our results. So maybe we influenced other teams, but I don’t know if other teams influenced us. (ID = 014) |
• M: are they supportive of D2D because they know other FHTs are participating? Does that factor in at all? R: No, I don’t think so. (ID = 016) |
• M: At the very beginning, you mentioned that you were aware of other organizations participating in D2D. R: Yeah, other family health teams. M: Did this impact the support for D2D in your setting? R: Yes, it did. (ID = 008) |
• Yes, other people participating doesn’t really drive our D2D work. It’s great, the more people share, the better idea we have of the benchmarking in terms of generalizing it. But, in terms of working with other people in the area, other organizations like ours, that really doesn’t matter, I don’t think, too much. (ID = 018) |
Perceived obligations
• So I think we participate, really to be good, corporate citizens. I think AFHTO does good work, and if we can help them do that good work, then that’s why we’re doing it. (ID = 001) |
• We just want to participate and be an active member for AFHTO. (ID = 007) |
• I think, just as my bias, I am on the AFHTO board. So, to be part of the board, you need to be very, very supportive in the initiatives that come our way. (ID = 003) |
• …we actually have some people with our FHT that have helped influence D2D. They’ve been asked to be on some steering committees and stuff. (ID = 017) |
• Name-X, just so you know, and you probably do know already, Name-X is on the Board of AFHTO, and Name-X is on the Indicators Working Group. I’m on the Steering Committee, and I’m head of the DM Management Group so we do have a high-level view of this. (ID = 014) |
• Well, it doesn’t hurt that I sit on of the indicator working group ... And so, I would have to say that we didn’t get a lot of pushback from our board when we suggested starting to get involved with this, because they probably want to support what their ED [executive director] and lead physicians are involved with. (ID = 002) |
Inner setting
Availability of implementation champion
• Really, it started with the leadership from our Quality Improvement Decision Support Specialists in terms of their working relationship with AFHTO. They were really the cheerleaders for D2D and trying to fan that out across the Family Health Teams that they support, promoting the value of using D2D and encouraging people to contribute data. (ID = 018) |
• The executive directors of those nine FHTs, we meet once a month, and these are the sort of things we discuss at those meetings. It really was with … Our quality decision support specialist, really kind of pushed it too, and he was there to help us get the information. That made it a bit easier. (ID = 015) |
• Well, no, at first I was always curious, but we didn’t have anybody. We had a lot of turnover in our staff, so it would have been me, and that’s really not my role. So, it wasn’t until Name-X came on board, our QIDSS specialist, he’s extremely helpful in guiding us and supporting us in his role. So, that’s when we started to … he’d come up and spend a week with us. So, that’s when we said, okay, if we’re going to take part, we should take part and we have this assistance. He’s kind of guiding us. (ID = 008) |
Development of QI capacity
• It’s hard to say because we didn’t really have quality improvement in place before. So, it’s been a great vehicle to advance it. So, at the time, when our organization was old enough to be able to start thinking about quality improvement, that is when it started. So, we could vote as a team. So, we have really grown up with it. So, it’s, maybe, been a consolidating focus. (ID = 013) |
• When we started to involve ourselves in quality improvement initiatives in a more formal capacity, we recognized the need to, I guess, retool the organization in terms of training, in terms of resources, to be able to do it properly. We didn’t have the internal expertise to do that. When we were able to hire QIDSS as an improvement decision support specialist that was very helpful, but still having more of a formal process in place that would allow us to structure and tap into data in a more meaningful way was helpful. D2D seemed to provide a method for us to be able to do that, and one that was aligned with more of a provincial initiative as well, so we didn’t feel like we were doing this on our own, but in fact was part of a larger quality improvement community that was engaged. (ID = 005) |
• We wanted to participate because we knew the importance of being able to measure the work that we’re doing and we didn’t know how to do this in a meaningful way. We didn’t know if we wanted to ... We thought the D2D would help support us, would help us look at what we are able to measure, what we’re struggling to measure, help us in ways that we’d be able to get that information and be able to compare it with the other family health teams across the province. We wanted to be able to measure how we’re doing, to be able to compare ourselves with other similar groups throughout the province, but knowing that, for us, we were just starting the measurement process. And we wanted to know what we’re able to do and what our limitations were. (ID = 012) |
Intervention characteristics
Promise of what the intervention will become
• Yes I do, and I think that that need is right now mostly based on a promise. The promise is what is going to happen with future iterations, and that its going to continue to develop until it actually is a robust, useful, accessible, meaningful exercise. I think we’ve taken initial steps towards that, but we need it to continue in that area. (ID = 014). |
• And it’s a good thing to be involved because you’re getting data and you can compare it to the other teams in the area, whereas, really there isn’t a system out there that was doing that before D2D. (ID = 006). |
• I think some of it was the data that we were getting from the Health Data Branch was so old that we wanted something that was more up to date and D2D was offering the ability to pull the more up to date data. Because Health Data Branch is always a year or two years behind. That really was part of it. (ID = 015). |
• So, we don’t have any other quality person. So, I don’t have time to be combing through all these reports. So, D2D is the one-stop shop. (ID = 013). |
• That said, though, D2D has that … unlike many other reports that are out there, it is very much about what the members want and what the members see as valuable (ID = 003). |
Evidence base
• I don’t know of any evidence that they put forward to except that they did mention Dr. Starfield as a … her research project about how she studies those three principles of cost, quality, and capacity. And so, there was that as a framework that they were using that I thought was brilliant as far as going that route, and using that as the principles of where they wanted to go with measuring for primary care … It helped me sell it within my own self, that we were on the right track. So I’d have to say, I’ve been excited about being involved with it because of those principles. (ID = 002). |
• I don’t think I have to go to my IT expert and say, do you think measuring how we’re doing is a good idea? It just kind of is. I don’t know how else to say it. I never presented to the group what was the evidence base behind D2D. To me, it was like, this is good for QI, this is good for accountability. That makes sense to all of us, let’s go for it. (ID = 017). |