Exploring role clarity in interorganizational spread and scale-up initiatives: the ‘INSPIRED’ COPD collaborative

Across the healthcare sector, there is a shift towards models of interprofessional collaboration (IPC) to provide integrated care for patients with complex health needs. Of the Canadian Interprofessional Health Collaborative’s six core competencies for IPC, role clarification is perceived by health professionals to be among the most important for collaboration [1, 2]. Role clarification is the process by which professionals develop a clear understanding of their roles and the roles of others and use this knowledge to achieve patient goals [3]. Role clarity is associated with improved care coordination and professional autonomy balanced with interdependence [4], while ambiguity about responsibilities can lead to conflict and tension [5‐7], service duplications or gaps [5, 8, 9], and underutilization of professional expertise [1]. Recognition of role clarification as a valuable collaborative tool is reflected in growing opportunities for students in healthcare fields to develop this skill [10].

The increasing prevalence of chronic disease in North America coupled with patient preference for care in the home presents a growing demand for high quality transitions from hospitals to community services. To ensure the success of new IPC interventions in this field, hospital staff and community practitioners need to be able to understand the diverse roles both within their own teams [11] and within their partner organizations [12]. Current literature describes the processes of role negotiation and clarification within and between hospital teams and reports that open communication [13, 14]; collaborative experiences [15]; change champions [6]; and work environments which value mutual respect, interdisciplinary collaboration, and patient-centred approaches [16] facilitate role clarification. Effective leadership that supports role clarity can range from being ‘manager centred’ to being ‘subordinate centred’ [7] and should plan for the integration of new roles, as well as facilitate and formalize IPC activities [5‐7]. Conversely, barriers include poor understanding of others’ scopes of practice [17], limited personal familiarity [15], differences in professional cultures [18, 19], and hierarchical team organization [20].

To our knowledge, literature is lacking on role development both at an organizational level among hospital and community partners in chronic disease transitional services, as well as in spread and scale-up initiatives. The ‘spread and scale up’ strategy is an emerging approach for disseminating change in the healthcare sector, often coupled with quality improvement (QI) initiatives. In contrast to the frequently used ‘scale-up and spread’ framework, in which a successful pilot project is scaled-up to benefit more people and then is spread across a number of healthcare settings [21], the Canadian Foundation of Healthcare Improvement (CFHI)‘s ‘spread and scale-up’ model recognizes the historical difficulty in spreading innovative practices and focuses exclusively on the dissemination process. The spread phase here continues to refer to the adaptation and implementation of innovations across a geographic area, while the scale-up phase in this case refers to the growth of these secondary programs [22]. Recognizing the complexity of innovation dissemination is the first step in planning for its success. Spread and scale-up QI initiatives could present unique implications for role clarification since they may warrant the participation of a third party that directs different iterations of the program, as well as permit interactions between teams at different sites.

The INSPIRED (Implementing a Novel and Supportive Program of Individualized care for patients and families living with REspiratory Disease) Outreach Program™ is an evidence-based model that addresses gaps in chronic obstructive pulmonary disease (COPD) care by promoting interprofessional collaboration, self-management education, and coordinated outpatient support [23]. Impressive improvements in patient outcomes observed at the Queen Elizabeth II Health Sciences Centre in Halifax prompted the spread phase of implementation, known as the INSPIRED COPD Collaborative. This national dissemination program was launched in September 2014 by the Canadian Foundation for Healthcare Improvement (CFHI) with support from Boehringer Ingelheim (Canada) Ltd., and engaged 19 healthcare teams across Canada. Two prior publications describe experiences of participating in the program and in the spread of the INSPIRED approach [24, 25]. Building on these results and to address existing knowledge gaps, we examined role clarification in the INSPIRED COPD Collaborative to investigate two questions: i) how does the spread of QI initiatives impact role clarification, and ii) how does role clarity develop between hospital and community health organizations working together to transition patients from one system of care to another? Characterizing role clarification in these contexts would further the current understanding of collaborative practice and its implementation.

The implementation of the INSPIRED COPD Collaborative occurred between Sept 2014 and Sept 2015. A previous study examining general team processes, health outcomes, context, participant perspectives, partnerships, program reach, and sustainability in the INSPIRED COPD Collaborative was conducted using final reports, surveys, key informant interviews, focus groups, and self-rating exercises [25]. Details about the data collection method can be found in a recent paper [25]. For the current study, notes from key informant interviews (KII) and focus groups (FG), as well as final reports (FR) from the aforementioned study were deemed sufficient to support a contextualized understanding of role development (see Table 1). KIIs, FGs and FRs were gathered at the end of the 12-month period and were designated a number (1–7, 1–3, and 1–19 respectively) for identification in this paper. Because data collection was completed prior to the start of this study, we conducted qualitative secondary data analysis using asynchronous purposive coding methods to identify key themes pertaining to role clarification [26]. Initial coding was conducted by a researcher who was not a part of the original study or the data collection process. Constant discussion throughout data analysis was maintained with a leading researcher of the INSPIRED COPD Collaborative, and all conclusions were verified by both researchers. All research team members supported an iterative and continuous analysis process through discussion and manuscript development.

Below we report our observations on role clarification in the context of a QI initiative in its spread phase and in the context of interorganizational partnerships for chronic disease transition care.

The construction, reinforcement, and defense of professional boundaries are important means by which practitioners understand their profession, establish authority, and maintain their status [19, 20]. Consequently, many individuals experience role changes as threats to their professional identities, particularly when role overlaps require them to relinquish their traditional responsibilities [5, 7] or when professionals have conflicting expectations of each others’ roles [2, 19]. Practitioners can become distrustful and resist collaboration by attempting to reestablish their authority and norms [17, 27], as well as by questioning the value of new interventions [1, 20].

Formal and coordinated interprofessional collaboration is a growing trend and necessary skill in the healthcare sector, emphasizing the integration of health disciplines to provide comprehensive and efficient care for complex health needs. Role clarification is thus a critical process in the shift from traditional systems of silo’d care to an interdisciplinary model, which may require practitioners to adjust their roles to better support collaboration [28, 29]. In this study, we explored the negotiation and delineation of roles in the spread phase of a QI initiative that aimed to foster partnerships between hospitals and community health organizations.

Our data show that QI initiatives can offer unique benefits for role delineation by providing an initial team framework, as well as by providing opportunities for communication between different sites. These meetings, both virtual and in-person, allowed teams to share their experiences, difficulties, and solutions, including those directly or indirectly impacting role clarity. Through its emphasis on multi-tier and interorganizational partnership, the initiative also encouraged in some cases a high degree of role learning between decision makers and frontline staff, while fostering an overall greater appreciation of other health professions along the entire continuum of care in virtually every team. While the process for the former is not clear, teams did note that the national profile of the INSPIRED COPD Collaborative helped to enforce among senior level executives the importance of continuous COPD care and of key health professions. The external accountability of national QI initiatives may thus provide a motive for health care institutions to adopt comprehensive and inclusive improvement strategies. Conversely, the heavy time commitment of participating in the INSPIRED Collaborative reported by all teams may have impeded role clarification. Time constraints are reported as the greatest barrier to resolving role clarity issues as they interfere with the ability of professionals to attend group meetings and to engage in multidirectional, day-to-day consultation [8, 15, 30]. We suggest that future QI initiatives should capitalize on the features that promote role clarification while minimizing the required time commitment.

The rising prevalence of chronic disease highlights the importance of interorganizational partnerships in supporting continuous patient care from the hospital back into their communities and homes. To successfully integrate care, hospital and community partners need to understand what service resources exist and how responsibilities are distributed between organizations and individuals. We found that communication was crucial for role clarification in the INSPIRED interorganizational partnerships, similar to what is reported among smaller, less diverse teams. Communication that is both formal and informal [6, 8, 13], multidirectional, and frequent [14] has been suggested as a prerequisite for role clarification because it allows practitioners to explain their roles, suggest areas of contribution, and ask for clarification on their colleagues’ practice. Furthermore, the importance of regular communication supports existing conceptual propositions that role clarification is an iterative process: roles are not adequately defined once, but are negotiated, adapted, and reinforced through day-to-day activities [6].

In addition, effective leadership that fostered role clarity among organizational teams was uniquely consistent in its high regard for consensus when compared to interprofessional teams within a single hospital or hospital department. Leadership within the latter may use consensus to arrive at decisions or may be seen at the other end of the continuum, in which the team lead or manager assigns roles to individuals with or without their input [6]. Managers in these hierarchical situations may also be solely responsible for orchestrating formal team development opportunities and reconfiguring existing systems to accommodate integrative practices [6]. Conversely, it was found across the INSPIRED COPD Collaborative teams that participation from all stakeholders was highly valued in the program planning process, and that leaders were needed primarily to support coordination and accountability, rather than to assign roles. Role delineation between organizations thus benefitted from a culture of equality.

Finally, the stages and structures for role clarification were more strictly observed at the organizational level than is commonly reported within smaller, less diverse teams. This process in the INSPIRED COPD Collaborative was characterized by role conceptualization and early contact, followed by learning and familiarization, and finally, role division. When hospitals and community services initially came together, the lack of knowledge of what the other could offer could impede further collaboration. Successful teams exceeded this stage by taking time to learn about the other organization’s goals, resources, what they could provide, and what they wanted to provide. This process of familiarization put partners in an informed position to brainstorm which services they wanted to see, from hospital admission to discharge to home visits, and to figure out who could best provide those services. Such consistent phases are not observed in smaller, less diverse, intraorganizational teams, where inclusive planning, mutual buy-in, and consensus are not the only approaches. The organizations in the INSPIRED COPD Collaborative also tended to implemented a number of formalized structures to facilitate interprofessional collaboration, including working groups, action plans upon patient discharge, and new information-sharing systems. Intraorganizational teams in the literature, on the other hand, have employed collaborative strategies that vary in formality. These include, for example, holding occasional meetings to articulate roles [13, 15], participating in interprofessional education interventions, or adopting structural changes, such as new charting practices and team rounds [1]. In acknowledging the high degree of structure in the INSPIRED COPD Collaborative, this study supports a recent publication that describes formalization as a unique characteristic of interorganizational partnerships [31]. We propose that not only does role clarification and formalization influence each other in a reciprocal manner, but also that this need for consistent formal interactions comes from a combination of greater professional diversity, less opportunity for direct contact, and the involvement of more stakeholders.

Role clarity is an essential, but often challenging aspect of IPC that can influence the success or failure of healthcare innovations. Faced with the growing need for efficient systems to deliver high-quality care, an understanding of role clarification processes among both individual professionals and among organizations will greatly improve our ability to design and implement integrative patient-centred programs.

Role clarification is a dynamic process in the adoption of interprofessional practice. Findings from the INSPIRED COPD Collaborative demonstrate that role clarity develops uniquely in both QI spread initiatives and in interorganizational transition care initiatives. As a QI spread program, the INSPIRED COPD Collaborative supported role clarity by providing a role framework, opportunities for regular communication between teams and stakeholders, and a national profile, although the time commitment posed a challenge for providers. In addition, role clarification in interorganizational partnerships was characterized by more procedural and systematic structure compared to smaller, less diverse healthcare teams. As the trend towards integrated care continues to grow, understanding how providers and organizational partners negotiate their roles in a changing professional arena can provide valuable insight into how to optimize quality improvement initiatives.