The FORGE AHEAD clinical readiness consultation tool: a validated tool to assess clinical readiness for chronic disease care mobilization in Canada’s First Nations

The objective was to develop a validated Clinical Readiness Consultation Tool (CRCT) to assess the readiness of clinical teams working on-reserve in Indigenous communities before they engage in QI efforts to enhance diabetes care in Canada. A consensus approach [23] within the community-based participatory research framework was utilized to develop and test the CRCT. Community-based participatory research emphasizes the recognition of a community as an equal partner and stakeholder that collaborates in all phases of the research [24]. Actions and decisions are made in a co-learning and knowledge sharing domain that facilitates research built on community strengths and adapts to community priorities to maximize both researcher and community benefits [24, 25]. The emergence of a co-operative model for health research and practice based on consensus with community partners is not new. The idea of working with communities rather than on communities is consistently recognized as a critical factor in research with Indigenous partners [23, 24, 26, 27]. The consensus approach based on the community-based participatory research framework differs from traditional approaches such as the Delphi process where emphasis is placed on expert knowledge and advanced detailed planning. Such traditional approaches have been documented as inappropriate when conducting health research with Indigenous community partners [24].

FORGE AHEAD partners with 11 First Nations communities across 6 provinces (BC, AB, MB, ON, QC, NL) and three isolation levels (isolated, non-isolated, and remote-isolated/semi-isolated).

A literature review was conducted in March 2014 using PubMed to identify existing clinical readiness tools published prior to January 2014. Key search terms included “Indigenous” or “First Nations” or “Aboriginal AND “healthcare” or “primary healthcare” or “chronic disease” AND “clinical readiness”, or “clinical change readiness” or “organizational readiness” or “organizational change” or “change management”. With no tools found in the Canadian Indigenous domain, the search was expanded internationally, included all populations, and examined grey literature for key content. A total of 13 PubMed articles and four grey literature articles/sources were found. Inclusion criteria included use in Indigenous populations, a health domain tool, and restricted to clinicians (versus patients).

Members of the Working Group which consisted of experts in the fields of readiness, Indigenous research, survey development and chronic disease care/epidemiology assessed the literature to identify the most appropriate tools for use within FORGE AHEAD. From the review of literature, the Chronic Care Model [28], Expanded Chronic Care Model [29], Assessment of Chronic Illness Care (ACIC) tool [30] and the Audit and Best Practice for Chronic Disease – Systems Assessment Tool (ABCD-SAT) [31, 32] were identified as key tools that examined organizations for strengths and areas to target for improvements or degree of readiness. The Chronic Care Model and the more health-promotion focused Expanded Chronic Care Model are both conceptual frameworks that guide implementation of chronic care, but cannot be used as practical tools to assess healthcare team readiness to address chronic disease change [33]. The ACIC and the ABCD-SAT, adapted from the ACIC to fit the local Australian setting, were both based on the concepts of the Chronic Care Model and emphasize system-level factors in the health setting for chronic disease change. Compared with the original ACIC scale, the adapted ABCD-SAT included three additional items (i.e., cultural competence, pathology management, and pharmacy management) [32]. The ABCD-SAT has been used extensively in Indigenous communities and health services in Australia, was designed to understand the state of development of health centre systems and inform decisions regarding priority areas for system improvement [32]. The ABCD-SAT is administered to a group of healthcare providers (managers, nurses, physicians) by external researchers or an external facilitator who guides the group through the components in the tool. The facilitator has been recognized as an integral part of using the ABCD-SAT with clinics who have demonstrated a level of engagement, interest and commitment to quality improvement.

The aforementioned existing tools (Chronic Care Model, Expanded Chronic Care Model, ACIC, and ABCD-SAT) were considered for the FORGE AHEAD program; however the following drawbacks were identified: i) reliance on costly resources external to the community for tool implementation and/or interpretation, ii) not tailored to the unique Canadian setting and First Nations primary healthcare setting, iii) not focused on type 2 diabetes, iv) lack of a qualitative component where Indigenous team members’ can add information regarding their insights and perceptions regarding diabetes care, and, v) no built-in mechanism to integrate individual perceptions to be used to support clinical readiness at a small group level. Therefore, the FORGE AHEAD Program aimed to develop and test a CRCT relevant to diabetes care in the Canadian Indigenous context that could be applied by primarily using existing internal community resources without the need for external interviewers and transcription. The ABCD-SAT (Version 2) was selected by the Working Group as the basis for conceptualizing and developing the CRCT. The overall goal of the Working Group was to develop a comprehensive, user-friendly, understandable, and stand-alone questionnaire that could be administered and used by community-based facilitators (rather than external interviewers) in First Nations communities within the FORGE AHEAD Program to assess readiness to adopt chronic disease interventions.

Adapting the ABCD-SAT into the CRCT involved a thorough review by Working Group members over a series of six rounds from January to July 2014. Each of the components and sub-components as well as the individual items that encompass the sub-components of the ABCD-SAT were reviewed for relevance to the context of Canadian First Nations primary healthcare delivery systems, redundancies, cultural relevance, and language. One item was added on cultural competence and two questions about registries were removed. Type 2 diabetes specific examples were inserted to enhance clarity in most items. All items were revised to reflect the Canadian First Nations context and the language was adjusted for improved clarity and ease of understanding.

In June 2014, 15 people from 7 provinces comprised of 3 co-investigators and 12 Indigenous and non-Indigenous community members from 11 partnering communities received the pilot CRCT. This group was selected given their prior involvement in the planning and development of the FORGE AHEAD Research Program proposal. Community members included family physicians, nurses, health managers and administrators, health promoters, and adult educators. The draft CRCT was distributed electronically along with a feedback form (see Additional file 1) that was designed to gather information on a five-point Likert scale on how respondents perceived the following: (1) appropriate language use for First Nations health clinics in Canada, (2) clarity of questions, (3) relevance of questions to health clinics in First Nations communities, (4) appropriate format for the tool, and, (5) helpfulness of examples provided for each question to complete the clinical assessment tool. A qualitative (open-ended questions) section asked respondents for suggestions, comments and specific recommendations. Respondents were asked to complete the questionnaire and insert comments in the questionnaire, as well as fill in the feedback form. To summarize the data, scores were tallied for each of the five scored domains and short responses and suggestions for improvements were summarized. All feedback received was incorporated into the revisions. The CRCT was deemed acceptable in each domain if a score of 3 or higher was received and if qualitative feedback did not raise concerns.

To evaluate the technical quality of the CRCT, internal reliability analysis and convergence validity were conducted. Individuals involved in patient care from each of the FORGE AHEAD partnering communities were asked to complete the CRCT as part of the program intervention. A total of 53 clinical team members from 11 First Nations communities (3-5 FORGE AHEAD program participants per community) completed the CRCT at three time points: pre, during, and post program implementation. For this study, only pre-program implementation data was used to avoid a learning effect bias.

The internal reliability assessment was based on the correlations between the individual items that make up the sub-components, relative to the variances [34]. The internal consistency of each sub-component was calculated using Cronbach’s alpha (α) which measures whether a group of items is related to a single construct or sub-component [35]. The higher the average correlation among the items, the higher the α but an α greater than 0.9 may also be indicative of a redundant item. An α greater than or equal to 0.7 is considered satisfactory (34). Sub-components with a single item were excluded from the internal consistency analysis. Overall α for the total scale (CRCT) was not calculated because each sub-component is intended to measure a distinct factor. Missing data was handled through pairwise deletion (available-case analysis) of cases. Descriptive statistics were generated to evaluate the score distribution and proportion of missing data per item. Items with high levels of missing data (>10%) were identified and considered for further analysis and interpretation.

As part of FORGE AHEAD, participants also completed the Team Climate Inventory (TCI) to examine team functioning of clinical teams working on-reserve. The TCI (19 items divided into four subscales with either a 5 or 7 point-Likert scale) has been validated [36] and used in a variety of contexts [37]. The CRCT includes a sub-component that measures Team Structure and Function (TSF) with five 12 point-Likert scale items. Convergence validity analysis was carried out assessing the correlation between the scores of the TCI and TSF to evaluate the degree to which these tests assess the same construct [38]. Data was used in this analysis only when both tools were completed by the same individual during the same time period (pre-program implementation). The total score for each individual scale was calculated for each participant who completed both questionnaires. Pearson correlation, appropriate for interval scale data [39] was used to assess convergence validity. Statistical Analysis Software (SAS) version 9.2 was used to conduct the validation analysis.

The 27-page CRCT (see Additional file 2) has 4 main sections: 1) 1-page introduction describing the background, confidentiality, benefits, risks, reimbursement, consent, and contact information; 2) 1-page brief instruction (estimated time to complete, brief description of rating scales and how to submit the completed questionnaire); 3) general information (brief 8-item demographic profile); and 4) 5 main components and sub-components of healthcare systems important in chronic disease care (aligned with Expanded Chronic Care Model). The questionnaire is designed to be anonymous and provides a section to insert participant numbers.

A total of 74 items comprise the CRCT. Data on the general demographic characteristics of respondents were collected using the first 8 items. The rest of the items are categorized into 5 major components and a total of 21 sub-components (Table 1). The 5 components include Delivery System Design, Information Systems and Decision Support, Self-management Support, Linkages with Community Resources and Other Health Services, and Local Health Center Organizational Influence and Integration. Each sub-component consists of between 1 and 6 items and often includes an example. Items were rated on a four category 12-point Likert scale defined as ‘limited or no support’ (score 0–2), ‘basic support’ (score 3–5), ‘good support’ (score 6–8), and ‘fully developed support’ (score 9–11). For each category, brief descriptions guide participants to consider the score that best represents their clinical context. A justification box was provided below each item/rating scale for participants to explain their rating of provided written comments. Responses by each clinical team participant are calculated and summarized in an aggregated group report.

A total of 8 respondents from 4 provinces (2 Co-Investigators, 6 community representatives from 6 First Nations communities) completed the feedback form for an overall review and response rate of 53.3%. The CRCT took an average of 118 min to complete and ranged from 53 to 240 min. Based on the five-point Likert scale feedback form, average respondent scores were: appropriate language use for First Nations health clinics in Canada (3.75); questions clearly written (3.25); questions are relevant to health clinics in First Nations communities (4); format of the tool is appropriate (4.5); and, helpfulness of examples to complete the clinical readiness assessment (4). The 12-point Likert scale of the CRCT was maintained based on the qualitative feedback. Analysis of the written answers to open-ended questions revealed that although the questionnaire was long, respondents found that all the questions were important and necessary to obtain a comprehensive understanding of the current services available in communities. Some respondents noted that the language was geared for higher education/reading and comprehension skills. Revisions to the tool were made following the pilot to improve clarity to address this concern.