Our findings are presented in two sections. For each case, we present a brief synthesis of the implementation of PP initiatives from initiation to sustainability phases. Then, we focus on key managerial practices used to implement PP in QI.
1. Implementation of PP initiatives in the two cases
Both cases implemented the Partners in Care Program in 2013 within voluntary clinical teams and benefited from methodological support from UofM during the first year. HCO 1 implemented the program in the ambulatory mental health hospital services unit (case 1), and HCO 2 tested it with its breast cancer unit. Table 2 provides
a summary profile of each case and Tables 3 and 4 synthesize the key events that happened between initiation and sustainability of PP in cases 1 and 2.
Table 2: Summary profile of the cases
Characteristics of the cases
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Case 1
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Case 2
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Type of HCO
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HCO 1
Integrated university health and social services center
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HCO 2
Integrated university health and social services center
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Location
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Rural setting
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Urban setting
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Initial models of PP
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Partners in Care Program
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Partners in Care Program
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Clinical settings
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Mental health
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Oncology
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Clinical units
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Ambulatory hospital services in mental health
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Acute services, breast cancer
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Composition of QI teams
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Program manager, psychiatrist (medical chief), psychologist, occupational therapist, nurse, two PAs, two ICLs
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Program manager, radiation oncologist (medical chief), oncologist surgeon, psychologist, two PAs, one ICL
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Examples of QI activities with PAs
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At clinical team-level: improving patient pathways within ambulatory mental health services; assessing daytime hospital services; adapting physical activities to patients’ needs
At other levels: developing an information platform for wait times; kaizen to review process and tools for recruiting PAs; facilities development projects
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At clinical team-level: developing educational activities on life after breast cancer; integrating PAs to facilitate pre-surgery classes for breast cancer, developing strategies to promote educational activities on breast cancer
At other levels: developing educational activities for patients with cancer, improving the cancer care and services continuum
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Table 3: key events between initiation and sustainability of PP
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Case 1 – Mental Health
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Initiation
2013-2014
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· Initiation of Partners in Care Programs in two clinical teams
· Initiation of a large-scale partnership approach in the HCO
· Department of research and professional practices responsible for implementing the PP
· Recruitment of a PA to help the department structure and implement PP activities
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Implementation
2015
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· Development of a reference framework for PP and elaboration of a logic model to organize the integration of PAs in QI
· Development of a five-step process for involving PAs in QI
· Presentations on PP made at different levels of the HCO and explanatory documents of the PP approach
· Mental health team completed two QI cycles with two PAs and support from UofM
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Sustainability
2015-2017
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· HCO merged with eight other HCOs following Quebec healthcare system reform
· CEO decided to continue and adapt the PP approach in the new HCO
· Quality department responsible for implementing PP
· Mental health team completed seven QI cycles with PAs and 200 PAs involved in several QI activities at different levels within the HCO
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Table 4: key events between initiation and sustainability of PP
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Case 2-Oncology
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Initiation
2011-2013
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· Launch of major projects on collaborative practices within the HCO
· Strategic committee set up to plan collaborative projects and four clinical teams selected to initiate the Partners in Care Program
· Department of multidisciplinary services responsible for implementing PP
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Implementation
2014-2015
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· Community of practice created to support the initiation of the Partners in Care Programs within clinical teams
· Brest cancer team completed one QI cycle with PAs and support from UofM
· Involvement of PAs in the co-construction and co-presenting with providers of educational activities for patients
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Sustainability
2015-2017
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· HCO 2 merged with seven other HCOs
· CEO decided to continue the PP approach in the new HCO
· Co-existence of two different PP approaches in the merged HCOs
· Two successive departments in charge of PP implementation (public health then quality department
· Breast cancer team completed four QI cycles and 10 PAs involved in QI activities within the oncology program
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2. Managerial practices for the implementation of PP
When implementing PP in QI, managers used four main types of practices: 1-designing the initiative so that PP makes sense to the entire HCO; 2-structuring the initiative to support PP implementation and sustainability; 3-managing PA integration in QI to avoid tokenistic participation of PAs; 4-evaluating PA integration in QI to support the continuous improvement of PP.
Designing PP so that it makes sense to the HCO
Designing PP involves making sense of the PP initiative relative to the entire HCO as well as creating a shared vision of PP among managers, providers and PAs. In cases 1 and 2, top (CEO, executive management) and mid-level managers (in the department in charge of the PP) integrated the PP approach into the code of ethics, positioning PP as one of the guiding principles of care and service. In both cases, the vision of PP was influenced by external requirements on patient engagement in HCOs, including Canadian accreditation standards and the objectives of the Quebec Ministry of Health and Social Services. Top and mid-level managers contributed to design a PP model that fostered its initiation (cases 1&2) and sustainability in a context of organizational change (case 1). In both cases, top-managers had to maintain an organizational vision of PP and reframe it to suit new organizational structures and responsibilities. In case 2, following the merger of HCOs, the lack of a clear vision from top-level managers, along with insufficient alignment between top-level, mid-level and front-line management regarding PP, compromised the sustainability of the PP model.
We’re in a strategic blur, a dense tactical fog, and operationally, we all do our own thing with the limited resources we have […] what we lack is a common project, support from upper management (Mid-level manager, case 2)
Case 1 used a range of design practices. First, mid-level managers developed a reference framework for the PP model which clarified the definition of partnership concepts. Furthermore, the mid-level manager in charge of PP, as well as the CEO, in tandem with a PA, gave several presentations about the PP approach to different clinical and management committees. The promotion of the PAs’ role and contribution in QI helped raise awareness of the added value of PAs and encouraged QI teams to involve PAs. In this regard, managers, in co-leadership with PAs, acted as ambassadors and disseminators of the partnership approach.
We received training on the concept of patient partners with all managers. Patients came to share their stories; we, as care staff, do not always have the patients’ perspective on the services we provide. It raised awareness among all managers. Then, the quality team started including patients, so everyone was on the same page, ready to welcome them (program manager, case 1)
Additionally, case 1 succeeded in ensuring the transfer of PP experience and knowledge among managers. Continuity among mid-level managers overseeing PP was determinant in the context of a merger to help sustain a vision of the PP model. One of the mid-level managers previously involved in implementing PP in the former HCO was able to share her knowledge and experience about PP with her team.
Structuring PP to support its implementation and sustainability
Top and mid-level managers played a key role in structuring the PP initiative to ensure its successful implementation and to facilitate its sustainability over the long term. By structuring PP, managers act as entrepreneurs in contributing to define the PP model. In both cases, executive management integrated PP into the strategic goals of the HCOs and appointed a department at the mid-level to oversee PP as a core function of the governance structure. In case 1, PP has been defined as contributing to a high quality of care and services.
That year, we integrated the partnership into the strategic objectives of our new organization. We want to place the whole notion of partnership at the heart of care and service quality (CEO, case 1)
In cases 1 and 2, different departments (best professional practices and quality departments) have been successively responsible for implementing the PP initiative. Structuring PP also required that mid-level and front-line managers organize the coordination of PP activities within the HCOs. In case 1, the coordination of PP was centralized in the quality department where mid-level managers developed a five-step process for PA involvement in QI: 1) PA request from a manager or a provider; 2) verification of the appropriateness of the request; 3) PAs’ identification and recruitment; PAs’ and QI teams’ training; 4) contact of the PA by the manager or provider to explain the QI project and the PA’s role ; 5) assessment of the PA’s participation within the QI project. On the other hand, in case 2, the coordination of PP was less formalised and was shared between the breast cancer program manager and the mid-level manager.
In both cases, the mergers destabilized the coordination of PP. In case 2, in the absence of effective governance of PP at top and mid-level management, several mid-level and program managers – previously involved in coordinating the PP activities in their former HCOs – have created a community of practice to foster the harmonization of the PP practices (e.g., PA recruitment, PA satisfaction assessments) in all clinical programs.
[…] as part of our partnership office, to better coordinate our actions, exchange tools and methods developed as much in hospital X as in hospital Y. We try to harmonize, we revised the patient request form and the patient satisfaction form (program manager, case 2)
In case 1, mid-level managers questioned the future role of the quality department regarding the coordination of all PP activities. As the number of PAs involved in QI has significantly increased in the merged HCO, mid-level managers have experienced challenges in maintaining personalized support for recruited PAs. They suggested that clinical programs could also take part in the coordination of PP, for instance, by creating a list of potential PAs, as well as PA recruitment and preparation.
Having personalized management for patient banks seems hard to maintain in such a large territory. I’m eager for us to think about this, because if we manage to reach 150 patients, I’m not sure that all patients will receive the same relationship and involvement quality (Mid-level manager, case 1).
Furthermore, structuring PP required middle managers to secure funds to compensate PA participation in QI activities (travel expenses, parking tickets, lunch), to ensure the recognition of PA involvement in QI and to encourage their ongoing participation. In case 2, mid-level managers questioned the sustainability of PA participation in QI activities given the absence of funding to compensate their work.
For highly involved people, who do more than volunteer, it would be fair to be able to remunerate them, but for now, we lack the structure and funding that enable us to do this. We have a budget from the X Foundation which allowed us to compensate patients who participated in activities, but this budget is running dry (Mid-level manager, case 2)
Managing PA integration to avoid tokenistic patient involvement
Managing PA integration in QI activities requires managers to select, recruit, prepare and coach PAs, to train providers/managers and to support their collaboration with PAs. These practices represent renewed practices that managers have developed over time to ensure the successful integration and involvement of a new actor (the PA) within QI teams. This range of new practices differs from their usual daily work, including adaptations of typical human resource practices geared towards a rather “unusual” human resource (the PA), especially in terms of selection, recruitment, preparation as well as training and coaching. These practices are carried out by mid-level and front-line managers, and are a result of a new type of relationship between managers and patients, who interact on a regular basis for QI purposes.
Selecting, recruiting and preparing PAs
Selecting, recruiting and preparing PAs are new practices that managers have developed over time to ensure the successful integration of PAs into QI teams. In case 1, managers systematically verified the appropriateness of involving PAs in a QI team before starting the selection process, to make sure that the QI project reflected patient concerns and that the PAs would add value. In both cases, program managers, in collaboration with providers, identified potential PAs while mid-level managers handled recruitment and preparation of the new PAs. In case 1, the middle-manager benefited from the support of an expert PA in these activities.
For both cases, PA recruitment was done through face to face interviews based on a set of core skills expected from PAs as set out by UofM. These skills are: having experienced services related to the QI committee; a stable health condition; effective communication; availability to participate in several meetings. In both cases, PAs were trained on PP principles and objectives, as well as PA roles and responsibilities on a QI team.
It was actually helpful to learn more about what a partnership is, what we can bring to the table as a patient, what our role and responsibilities are when we are involved in a team (PA, focus group with patients, case 2)
In case 2, providers reported the need to clarify PA roles and responsibilities, for instance, regarding access to and handling of confidential information.
Preparation is provided to new patients; it’s a must. X and team did that. Because patients arrive in good faith, yes, but sometimes there are things that are important for them to know. Like, the extent of their role. At least the notion of confidential information (program manager, case 2).
Team training
For both cases, during trials of Partners in Care Programs, QI teams were first trained on partnership concepts and methods by UofM. A specific effort was made to explain the roles and responsibilities of new team members, including PAs and ICLs. For both managers and providers, it was necessary that QI teams be trained and prepared to work in co-construction with patients before integrating PAs.
A major success factor is the thorough work that goes into preparing providers and patients before getting started, with help from UofM (top-manager, case 1)
The whole training that we had with UofM, I think, was very helpful, because we didn’t know much about partnership, what the role of PAs would be within our team (physician, focus-group with providers, case 2)
At the end of Partners in Care Program trials, each case adopted different practices to ensure QI team training. In case 1, the middle-manager, in partnership with an expert PA, systematically provided individual training for QI teams interested in partnering with PAs as well as an explanatory document containing information on PP principles, benefits and processes to be followed for PA integration. Involving a PA as a co-trainer helped the QI teams recognize the added value of partnering with patients in the QI process.
We always provide a training tandem: a Quality Advisor and a PA for new PAs and teams that want to integrate PAs. This tandem is a must! (Mid-level manager, case 1)
In this presentation, I remember that the patient shared her story, her experience as a patient. We realized that patients have valuable things to share with us to improve the services that we offer them (Psychiatrist, focus-group with providers, case 1)
In case 2, the mid-level manager created a community of practice, bringing together all QI teams that partnered with PAs. This community helped share experiences, practices, methods and issues related to PA integration, as well as develop a charter on good PP practices and methods.
Supporting collaboration between PAs and QI teams
Integrating PAs into QI teams required daily efforts from mid-level and front-line managers to support and stimulate collaboration among PAs, providers and/or managers. During the trials of Partners in Care Programs, ICLs helped program managers act as PP facilitators and helped ensure that PAs and QI teams mutually understood their roles and responsibilities. Meanwhile, the program manager also had to facilitate compromise when setting QI objectives so as to satisfy the concerns and expectations of PAs, providers and managers.
There is certainly a gap between my perceptions and concerns as a manager and those of professionals and patients. Our challenge is to find an objective that will connect everyone’s interests, particularly those of the patients if we want them to be involved (program manager, case 2)
In both cases, mid-level managers set rules to facilitate PA participation and their integration into teams: involvement of at least two PAs on QI teams; and assignment of a patient coach, who has PA experience, for newly recruited PAs. PAs appreciated the ongoing support of a patient coach. This coach encouraged PAs to express themselves and to share their expectations which helped their meaningful involvement on QI teams.
He gave me good advice to make me feel more comfortable expressing my opinions and expectations with the team, which I appreciated (PA, focus-group with patients, case 1)
Program managers faced issues related to continuous PA involvement on QI committees. In case 1, the program manager struggled with high PA turnover on the committee, for several reasons (medical condition, work). Finally, one particular issue was raised by the mental health QI team in relation to PA support once their involvement ends. For patients with mental health issues, participating in QI teams as a PA also represents a step towards recovery. Therefore, ending their involvement could be badly experienced if their exit is poorly prepared and if the PA transition is not supported by the team.
For patients, project or team involvement means a lot for their recovery as it becomes a benchmark for therapeutic success or failure, even though it is a collaborative relationship. I believe that PAs should be supported at the end of their involvement or shepherded in terms of what the end of their involvement means (Psychologist, focus group with providers, case 1)
Evaluating PA integration in QI to support continuous improvement
In case 1, mid-level managers from the quality department collected data to report on PP integration in QI activities. Collected data included: number of PA requests in QI; types and number of departments, programs or clinical teams involving PAs in QI; and different PA involvement purposes. Collecting these data helped case 1 to continuously monitor PP activities across the whole HCO. In case 2, a systematic collection of these types of data was not implemented in the quality department.
On the other hand, in order to ensure continuous improvement of PP, evaluating PP in QI mainly involved assessing the PA integration process by understanding how PAs and QI teams experienced their partnership. In both cases, this informal practice was carried out by program managers who inquired about PA satisfaction in terms of team integration and participation, and of potential areas of improvement. They regularly shared PA feedback during team meetings and, in turn, providers shared their own partnership experiences with PAs.
We have meetings with patients and professionals to assess participation – what went well and what went less well – so that everyone provides their opinion (program manager, case 2).
In case 1, since the coordination of PP was centralized in the quality department, the role of mid-level managers was to evaluate PP. The formal PA involvement assessment process relied on three main types of data: PA satisfaction with regard to their participation; PA benefits gained from their partnership experience; QI team members’ perceptions regarding PA contributions and PA partnership challenges. This formal assessment process helped the quality department to sustain continuous improvement of the PAs’ integration and to support QI teams that face specific challenges with PAs.
A summary of the findings is presented in additional file 2 and a graphic presentation of the main conclusions is provided in figure 2.