Processes of Transforming Primary Health Care in a Rural and Northern Health Region Martha MacLeod1, Cathy Ulrich2, Neil Hanlon1, Margo Greenwood1, Trish Reay3, Dave Snadden4, Craig Mitton4, Suzanne Johnston2, Fraser Bell2 1-University of Northern BC, 2-Northern Health, 3-University of Alberta, 4-University of BC
Findings
Purpose of Study To understand how networks of partners can be engaged to improve primary health care (PHC) at community and regional levels across northern BC.
Engaging in Conversations and Decision-Making in New Ways
Research Questions
• Creating regional coherence
• How can relationship-building and networking bring about system change? • What facilitates or hinders networking and partnering? • What are the implications for partners who are involved in PHC transformation? • What information can support efforts to realign health care?
Methods
• Conversing about aligned goals and actions “So now we’re talking about our work as opposed to our [NH] work and their [physicians] work. It’s now all – our work.” (Primary Care Facilitator)
“This is not about structure. This is about changing processes of care but we need a structure to enable it and that that structure needs to be relatively consistent across the organization.” (NH Executive)
• Talking about service integration that actually works for the patient
• Developing local-regional trust
“The overall need to integrate our services has crept into many areas of our work and it’s becoming sort of a cornerstone of almost all of our conversations. There’s a culture shift happening.” (Public Health)
“If Executive is saying we want you to figure out a way to provide the best care you can and nobody throws their hands up in horror when you do challenge some boundaries… then it’s easier for me to say in my teams, it’s OK to do that. With the understanding that sometimes you can do it, sometimes you can’t” (Community Care)
“A whole different conversation happened…they problem-solved … in a way they wouldn’t have done in the past.” (NH Executive)
• Multiple case study over four years (2011-2015) • 7 northern BC communities: Fort St. John, Mackenzie, Prince Rupert, Fraser Lake, Prince George, Valemount, Burns Lake
Working within the Complexities and Discomfort Associated with Change Staying the Course Despite an Uncertain Future
• Analysis: Thematic analysis. • Integrated KT: research findings are regularly brought back to NHA, physicians, and the communities in order to actively inform ongoing organizational changes at the local level.
• Moving strategically yet flexibly “There’s a lot of chicken or egg things in this process that you only realize as you get into it and sometimes you do have to take a couple steps back to sort it out.” (NH Executive)
Participants
• Trusting the process and the goal
Year 1
Year 2
Year 3
21 9 12 58 33 9 16 79
26 11 15 50 30 5 15 76
28 10 18 43* 27 4 12 71*
*Year 3 community interviews in progress
Funded by: Canadian Institutes Health Research Operating Grant: 2011-2015
“It’s a very different focus, even though our titles, our program content hasn’t changed, our process and functions have changed greatly.” (Community Care)
“We flip all this [our discussions about staff requirements] on its head now and look at it from the patient’s perspective.” (Regional Staff)
• Data: Interviews with community leaders, Northern Health Authority (NHA) staff, nurses, and physicians, along with documents (meeting minutes and NHA evaluation results).
Regional Interviews NH Board and Executive NH Administrators and Directors Community Interviews NH Staff and Care Providers Physicians Community Organizations/Municipal Leaders Total
Mobilizing Local Innovations within a Coherent Regional Direction
“There’s the temptation to hang onto what you’ve got, there’s a lot of concern about what’s things are going to look like. But I think there’s enough trust and confidence in the process to know that it’s going to be an improvement.” (Mental Health) “There might be tensions simply because of not knowing where we’re going to be at the end of the day, but to be honest there’s huge faith that where we’re going to be is going to be better than where we’re at." (Primary Care Practitioner) • The challenge of defining measurable improvements "It’s always there in the back of my mind that we need to be demonstrating progress and to continue to build trust. I struggle with that sometimes, how we define progress, how we evaluate the work that we’re doing and make improvements." (Public Health)
• The challenges of transforming, not fixing, a broken system “We’re not fixing a problem … we’re looking to eliminate the problem… or replace it with something that is going to make the whole system work better. Some days I still don’t have my brain wrapped around it, because as a nurse I’m used to fixing things.” (Home Care) “I think the biggest thing for me was living with the unknown and feeling comfortable with it… when you start to shake everything and you don’t know where it is going. It comes back to being okay not knowing …. And then letting it play out…. And then looking back and saying… OK now it is starting to make sense” (Primary Care Facilitator)
Summary and Next Steps Three years of findings show that PHC transformation can be achieved through processes of communicating a clear end-in-view that is centred on the patient, developing processes and functions that improve patient experience, holding a course despite the discomforts of change, supporting local developments within regional directions, and working in ways that develop and maintain trust among physicians, health authority staff, and communities. Next steps include a final year of interviewing at regional and community levels (spring/summer 2015), ongoing feedback to Northern Health and the study communities and physicians, and preparation of publications for a wider audience.