In early 2005 we conducted a study in the two most populous regions of Québec province (Montréal and Montérégie) which examined the association between prevailing models of primary healthcare (PHC) and population-level experience of care [1]. This study followed the launching of two reform policy initiatives by the Québec's Ministry of Health and Social Services: the creation of Family Medicine Groups (FMG) and the establishment of Local Services Networks (Local Networks) under the governance of Health and Social Services Centres [2]. FMGs were established to increase accessibility and continuity of care while Health and Social Services Centres (Local Centres) aimed at better coordinating and integrating services by creating territorially-defined Local Networks. Although these policies were respectively proposed in 2002 and 2004, implementation was only begun, for the most part, in 2005, coinciding with the conduction of the aforementioned study.
Four years later both reforms are well-established, and the question arises of how PHC models have evolved, what factors have promoted the evolution of PHC organizations, and how this evolution has translated into measurable effects at the population level. The decision-makers of the two regions have approached our research team to explore these questions. The study we conducted at the early phase of implementation of these reforms will provide us with a reference point for assessing the evolution of PHC organizations over a five year period. The study's goal is to assess the evolution of PHC organizations through the reform, identify factors associated with this evolution, and evaluate its association with the performance of PHC organizations and Local Networks. The knowledge generated by this study will help to further PHC reorganization efforts in various jurisdictions by better understanding factors that can promote organizational change and by better understanding the impact of this change on population-level experience of care.
Our project team includes researchers and decision-makers engaged in the co-production of relevant information in order to guide PHC reforms and optimize PHC service provision. By providing sound evidence for decision-makers and clinicians regarding factors related to the transformation of PHC organizations, we aim at supporting the implementation of PHC reform efforts and thus improve the performance of the healthcare system in addressing healthcare needs of Canadians.
The current reform of PHC organization in Québec
Health and Social Services Centres (Local Centres) have been created by law [3], merging acute care hospitals, long-term care hospitals and Local Community Services Centres (CLSC) on a geographical basis. Their main objective is to lead to the implementation of Local Networks and to increase collaboration among PHC organizations through the creation of these networks [4]. The Local Networks are composed not only of the facilities merged under Local Centres but also of all other health and social services providers, including privately owned medical clinics. There are 95 Local Centres and Networks in Québec, 12 in Montréal and 11 in Montérégie. Local Centres and Networks vary in composition since some have acute care hospitals while others don't. In addition, Local Centres benefit from a large autonomy in the planning and organization of services and activities.
The FMG policy consists mostly in developing a contractual agreement between PHC clinics and the provincial government. PHC organizations receive complementary funding in exchange of complying with certain organizational requirements identified in the FMG policy (e.g. extended opening hours). In addition, each FMG has a contractual agreement with Local Centres that enables them to benefit from the presence of a nurse. A FMG consists of 6 to 10 physicians who work together with nurses to provide services for registered members of the group, on a non-geographical basis (usually around 10,000 to 20,000 people per FMG). A FMG provides services both by appointment and on a walk-in basis. It aims at being accessible 24 hours a day, 7 days a week, through opening hours that extend into the evening (until 9:00 p.m.) and weekends (at least 4 hours), and through a regional on-call system (Info Health line) for vulnerable patients when the clinic is closed. The target established at the start of the reform was to implement 300 FMGs in the province. As of March 2009, there were 181 accredited FMGs in Québec, 42 in Montréal and 55 in Montérégie.
A complementary model of organization currently being implemented in the regions under study is the Network Clinic. These clinical settings are more specifically targeted to ongoing and integrated management of clients, particularly those considered "vulnerable", and to provide access to basic technical support, such as radiology, blood tests, and specialists [5]. Their creation was initiated by the Montréal Regional Health Agency as a complement to FMGs, in response to requests by the regional medical association. A clinic can concurrently have the status of FMG and Network Clinic, thus benefiting from two sources of funding. As of March 2009, there were 36 Network Clinics in Montréal, among which twelve had both FMG and Network Clinic status.
A recently completed research project
We recently completed the research project Accessibility and Continuity of Care: A Study of PHC in Québec which was conducted in two regions in the province--Montréal and Montérégie [1, 6]. It looked at organizational models of primary healthcare and their influence on accessibility and use of health services by the population, as well as the experience of users of these services. The main objective of the study was to identify organizational models of PHC that are best adapted and most likely to meet the population's needs and expectations. The research included three components: 1) a survey of the population designed to measure utilisation of health services as well as users' perception of the accessibility, continuity, comprehensiveness, responsiveness and perceived results of services received [7]; 2) a study of PHC clinics that aimed to describe the PHC organization models in the regions studied [8]; 3) a contextual analysis that sought to describe Local Networks [9]. We identified five models of PHC organizations. Four were professional models (one was a single-provider model, one was a contact model (walk-in clinics), and two models were coordination models, one being integrated and the other non-integrated in the overall healthcare system), while one was a community-oriented model. Overall, the integrated coordination and single provider models were associated with better patient experience of care, followed by the community-oriented model. The contact professional model was associated with the worst experience of care across all measures [1].
What does the literature tell us about PHC organizations?
Recent studies have focused on models of care, or ways to organize clinical services, that promote more accessible, coordinated, patient-centered care with emphasis on health promotion and disease prevention [10, 11]. Models of care such as the medical home and the chronic care models, among the most often cited, have shown a great potential for achieving such results [11–15]. However, researchers have paid much less attention to the structure and processes developed at the organizational level, in which these models of care can be implemented and which require certain organizational conditions for their successful implementation [16].
Several organizational attributes have been associated with a better performance of PHC organizations [17]. For example, physician payment modalities have a determining effect on their practice. Fee-for service is associated with greater productivity but less continuity of care when contrasted with per capita prepayment which encourages more continuity and prevention [18, 19]. Although it is possible to identify the effect of individual attributes of organizations on various process or outcome indicators, it remains more difficult to understand how these attributes relate to each other in actual organizations and systems. However, studies that focused on comparisons between different types of PHC organizations or systems (e.g. Kaiser or Veterans Administration) have provided enlightening results [20, 21]. Although differences between types of organizations could be due to specific organizational attributes, understanding the effect of various organizational characteristics in a systemic perspective remains a challenge [22]. Hence, there is a need for a more holistic view in the study of healthcare organizations and systems.
The configurational approach, which views an organization as a whole rather than a set of independent attributes, is instructive in this regard [23, 24]. This view seems to best meet the representation held by decision-makers of what an organization really is [25]. "In essence, a configurational approach suggests that organizations are best understood as clusters of interconnected structures and practices, rather than as modular or loosely coupled entities whose components can be understood in isolation" [26]. Configurations are "represented in typologies developed conceptually or captured in taxonomies derived empirically" [23]. Taxonomies are generally derived from cluster-analytic methods, thus forcing similar organizations to form homogeneous groups [26–29]. A complementary measure is a deviation score [30]. In this case, the researcher defines an ideal-type of attributes based on theoretical considerations and then calculates a score of conformity to this ideal-type, based on empirical observations [26].
One way to conceptualize various organizational models derived from the configurational approach is to consider them as a system for organized action defined by four sets of attributes: vision, resources, structure and practices [31]. As it applies to PHC organizations, vision corresponds to the values and representations shared by the actors [1, 16]. Structure refers to the interaction and regulation among actors, such as interprofessional collaboration, and governance. Resources are defined by the type and level of various resources (human and material) and their arrangement. Finally, practices comprise mechanisms for offering services, developing multidisciplinarity and ensuring follow-up of patients.
This approach has been used in our previous work. In a recent policy synthesis, we derived a taxonomy of four models: two professional and two community models [16]. Following the same methodological approach, but using data on PHC organizations in two regions, we derived another taxonomy that is very consistent with the policy synthesis. We found only one community model, but four professional ones: the single provider, the contact, the coordination and the coordination integrated [1]. In order to contrast models from a normative standpoint, we also constructed an index of conformity to an ideal-type, based on the literature on group practice and on the various policy documents on new emerging forms of PHC organizations (such as the FMG).
Not only do these models or archetypes provide an holistic view of an organization, compared to other forms of organizations derived from the same taxonomy, but they also permit the assessment of change over time, when an organization passes from one archetype to another [23, 25, 30]. Comparing archetypes or models specific organizations belong to at different points in time is thus a sensitive measure of organizational change.
What does the literature tell us about factors associated with PHC organizational change?
Institutional theory of organization has become widely used to explain organizational change [32–34]. According to this theory, the environment exerts a determining influence on organizations that tend to take a similar form within an organizational field (the sharing of common norms and values) leading to a certain degree of homogeneity called isomorphism [32, 35, 36]. In the public sector, geographically defined territories such as Local Networks can exert such an influence [37, 38].
Environmental pressures exerted on organizations are of three types: coercive, normative and mimetic [36]. Coercive pressures refer to laws, regulations and state policies. As Scott [38] points out, the state has the definitive ability to apply these kinds of pressures either by law or by introducing strong incentives in financing publicly-supported organizations. The two measures introduced by the Québec Government to create FMGs and Local Centres are essentially of this kind. Normative pressures are very prevalent in an environment of professional organizations such as the healthcare system. They refer to values and norms held by professional associations that tend to permeate organizational boundaries [33, 39, 40]. Hence, local professional associations and leaders have normative influences on PHC organizations through their links with professionals in these organizations [38, 39]. Finally, mimetic pressures stem from organizations considered as examples by others that tend to imitate them. FMGs and Network Clinics can be seen by other clinics as model PHC organizations, thus generating mimetic pressures on these clinics.
Although organizations within an organizational field tend to converge to some form of isomorphism in response to these pressures, they do not react exactly in the same manner [38]. There are intrinsic characteristics of organizations mainly related to dominant values held by their professionals and the role played by influential actors that make them more or less sensitive and receptive to these pressures [38]. For instance, clinics that already collaborate with other clinics may have a higher propensity to respond to mimetic or normative pressures [38].
These three types of pressure do not necessarily act in the same direction and they can even neutralize each other's influence. This was the case in the implementation of CLSCs (Local Community Services Centres) in Québec. The Government policy aimed to establish a public health and social services organization (coercive pressure) was opposed by professional medical associations which encouraged their members not to practice in CLSCs (normative pressure) and reactively developed a network of privately owned group practice clinics (mimetic pressure) [4, 41]. The opposition and reaction of the medical organized medicine to the CLSC project was a major obstacle in making CLSC the point of entry into the system. This illustrates the point that in order to yield maximum organizational change these pressures need to align in the same direction.
What does the literature tell us about the effects of PHC organizations in the context of reforms?
The contribution of PHC in achieving health objectives has been largely documented [42, 43]. Systems based upon well-organized PHC are better performing in many aspects, namely experience of care (continuity, accessibility, comprehensiveness, responsiveness) [42, 44]. They also report a more appropriate use of services, as reflected by a lower use of hospital and emergency care [45].
Reforms of PHC organizations and local organization of healthcare services have been the subject of various evaluative studies in Canada [46]. Studies in Québec, Ontario, Manitoba and British Columbia have highlighted the positive impact of new forms of PHC organizations integrating desirable attributes of experience of care [7, 41, 47–52]. Studies have focused on understanding the process of organizational changes using a case study approach [16, 53], linking experience of care and use of services provided by a limited number of organizations [48, 54], using administrative data files or population surveys. None of these studies have nominally linked services users with their regular source of care [55–57]. Overall, these studies have highlighted some benefits of emerging models of PHC in various provinces, with community-oriented models and those promoting coordination of care showing the best results regarding the experience of care of patients and regarding professional collaboration and satisfaction.
The gap in knowledge and need for evaluating PHC reforms
Ongoing or recently completed studies in Québec focus on various aspects of organizational performance [1, 48, 53]. One study explored factors associated with the implementation of FMGs [53]. A multiple case study approach found a positive association between nurse-physician collaboration and experience of care [58]. An ongoing study using a cross-sectional design is looking at the relationship between types of PHC organizations and experience and quality of care [59]. A study currently underway adopts a longitudinal perspective to look at the implementation of Local Centres and the impact on utilization and experience of care [60].
To our knowledge, no studies have assessed the evolution of PHC organizational models, identifying factors that can explain changes, and their impact on population-level indicators. In addition, we did not find studies that have assessed the impact of PHC reforms on the level of inter-organizational collaboration. Our study includes all PHC organizations in two large regions, a sample of the population with representativeness at the Local Network level and nominal linkage with the regular source of care. This evaluation of the evolution of models of PHC and of its population-level impact is required to guide the continuation and completion of the PHC reform and assess the improvement in capacity to respond to needs and expectations of populations. Such knowledge is crucial given the difficulties of reforming PHC in pluralistic contexts, such as Canada, and the relatively high costs that such reform demands. Decision-makers need to understand what promotes organizational change and how change and its benefits may be sustained.
Conceptual framework
Our conceptual framework is presented in figure 1. According to this framework, organizational models (OM) of PHC and the inter-organizational collaboration (OC) between PHC organizations influence the organizational performance (OP) of PHC systems. In addition, certain factors have an impact on the evolution of PHC organizational models and on inter-organizational collaboration through a period of transformation (Time 1 and 2). These factors relate both to the policies established by the Governments and to more implicit organizational environments.
The implementation of Local Centres and Networks is seen as exerting a coercive influence on the evolution of PHC organizations. We expect the integrating influence of Local Centres will increase networking as expressed by inter-organizational collaboration among all organizations within the territory. Specific interventions or regulations can in fact influence the ways PHC settings organize various aspects of care. Examples of such interventions can include the funding of specific initiatives by local health authorities, development of specific organizational projects under the impetus of coordinating bodies or modification of relationships between organizations because of restructuring services at various levels of Local Centres and Networks. The introduction of a new organization policy has a direct effect on the implementation of emerging forms of PHC such as FMGs through explicit policies aimed at promoting change in the way care is organized. The implementation of new forms of organizations can also have a mimetic influence on the other forms of PHC organizations and the inter-organizational collaborations in place.
In addition to these contextual influences, some characteristics and attributes of PHC organizations make them proactive or more receptive towards change. These attributes can be related to the presence of a designated team leader, or their organizational culture (e.g. concordance between dominant organizational values and current proposals of reform). Professional influence relates to the presence of leaders and professional organizations that apply pressure on PHC organizations towards accepting or opposing changes. These influences include elements such as the official position of medical representatives regarding specific policies or the presence of a local champion promoting a specific model of PHC organization.
These changes are expected to translate into an increased organizational performance at two levels: first, at the level of the clientele of these organizations and second at the level of the populations of each Local Network. We use performance here in a very broad sense to include various indicators of effects of PHC organizations [61]. We expect that change towards new forms of organizations at the level of Local Networks will be associated with improved population coverage (e.g. affiliation with regular sources of care and unmet needs for care), process of care (utilisation of services and patients' experience of care such as accessibility, continuity, comprehensiveness, responsiveness) and outcomes of care (e.g. perceived results of care, reception of preventive services, preventable hospitalizations and emergency room consultations) (see Additional file 1 for details of measures).
Study objectives
The goal of this research project is to understand the evolution of PHC organizational models and their relative performance through the process of PHC reform, and assess factors, at the organizational and contextual levels, associated with the transformation of PHC organizations and their performance. More specifically, the objectives are:
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1.
to assess the magnitude and direction of organizational change and migration among models of PHC, between 2005 and 2010, at the PHC organization and Local Network levels as expressed by: 1) the prevalence and local configuration of PHC organizational models; 2) conformity of PHC organizations to a normatively defined ideal-type of organizational characteristics; and 3) the degree of collaboration between PHC organizations within and outside the Local Network;
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2.
to determine the association of these organizational changes of PHC with factors related to the implementation of Local Networks and policies aiming at promoting new forms of PHC organization, as well as factors related to the receptivity of PHC organizations and the influence of professional associations;
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3.
to examine the association between these organizational changes and various indicators of PHC performance (coverage, process and outcomes of care), both at the organizations' clientele and the Local Networks' population levels.
