We chose a qualitative, exploratory multiple-case study approach for this study, following Yin’s design and methods (18). As OHTs are community-driven, a Yinian approach which allows for comparisons of similarities and differences between cases and seeks to understand “a contemporary phenomenon within its real-life context” (Dul and Hak, 2008, p.4; as cited in Yin, 2003) was fitting. The case study design followed a constructivist approach in which insights and interpretation is drawn from the lived experiences and perspectives of the participants. Consistent with this approach, we have adhered to a systematic progression of research components to remain true to the ‘yardsticks’ identified by Yin to ensure rigour in the research. These criteria include: construct validity, internal validity, external validity, and reliability (18). The uniqueness of each case further supported the researchers’ decision to use multiple-case study and allow for cross-case analysis and a deeper exploration of theory related to the need for structures and processes to support the participation of FPs in OHTs (Figure 1).
Phase I: Plan and Design
Study design
Burrell and Morgan’s (1979) sociological theories, specifically the principles within the functionalist paradigm, often used for organizational study, provided the theoretical framework for this research (19). Theories within this paradigm seek to understand survival and legitimacy of organizations; structures and processes designed to support ongoing participation and decision-making by FPs are functional in nature. A case study protocol was developed to provide guidance for research; it included the project workplan and definitions, roles and responsibilities of the project team members, a framework for data analysis, and timeline to completion. As per Yin’s approach to case study, the research questions that guided this investigation focused on the ‘how’ and ‘why’ of the phenomenon.
Phase II: Recruitment, Data Collection and Within-case Analysis
Setting
This study was conducted in Ontario, Canada. Purposive sampling was used to identify cases. Initially, we consulted with the ministry of health to identify OHTs that were not engaged in other research-intensive activities and deemed eligible to participate in our study. We identified an OHT Lead (Chair or Physician Lead) from each OHT and sent a letter of invitation by email, asking whether their OHT would be interested in participating in our case study. Five eligible OHTs were identified and invited, and four agreed to participate.
Recruitment of Participants
Following agreement with a lead at each of the four participating OHTs, we identified a gatekeeper for each case (usually the same Chair or Physician lead). The gatekeepers communicated to their OHT partners about the study, remained responsive to our frequent requests for documents as we learned of them, provided an initial list of key informants for interviews, and assisted with recruitment. In three of the four cases, gatekeepers also participated in interviews.
Key informants in each case included both family physicians and non-physicians who would provide diverse perspectives on participation in OHTs. A goal of 10-12 semi-structured interviews was established per case, aiming for 50% of family physician participants. A snowball sampling strategy was employed after each interview until the desired sample size was achieved. One interview guide was used for all participants. A gift card was provided to each participant in appreciation for their time.
Data Collection
Data were collected from three sources: key informant interviews, archival documents (pre-OHT stakeholder presentations, press releases), and administrative documents (meeting agendas, minutes).
The first data source for this study was key informant interviews. An interview guide was developed based on the ‘how’ and ‘why’ research questions and guided by the theoretical propositions identified at the outset that some degree of organization by FPs would enable their collective participation in OHTs. The three primary areas of questions included: how were FPs participating in OHTs, why was it important for FP participation in OHTs, and why were there challenges (if any) to achieving this participation. Three authors (###, ##, ##) conducted semi-structured interviews virtually. Prior to starting interviews, a group training session was held including a mock interview to ensure that investigators were using the same approach and that interview questions were clear. All interviews were audio-recorded and transcribed verbatim. In each case, interviews were shared between two investigators to provide optimal availability for participants.
The second data source was archival documents related to the four cases. This included past community network documentation (if any pre-empted the OHT), news/online stories, press releases or op-eds related to OHT development, and stakeholder consultations or presentations given prior to becoming an OHT. Prior to COVID-19, many communities promoted the OHTs and informed potential partners about the application to become an OHT. These discussions were documented and included Power Point presentations along with an attendee list.
The third data source included documents considered to be current and generated after approval of the OHT by the province. These included meeting minutes and agendas from steering and physician committees, and administrative documents related to the governance of the OHT (decision-making frameworks, OHT application, organizational charts).
All data (transcripts and documents) were stored in an encrypted drive accessible by three investigators.
Data analysis
Within-case analysis was completed by two authors (SCN, CG) using the data management system, NVivo 12. We followed the practice of double-coding or simultaneous coding. Each investigator coded a transcript independently, then compared coding, discussed nuances within codes to achieve consensus, and established a codebook. SCN and CG each took the lead in two cases, with one researcher completing the analysis of interview data while the other completed the document analysis for those same two cases, allowing rigour in analysis.
### and ## each summarized findings for two cases and presented to one another for group interpretation and discussion. The documents were read over to contextualize the major themes found in the study. Throughout data collection and analysis phases, we consulted the gatekeepers and collected additional documents to fill in gaps in information. The final themes were presented to the rest of the study team for review and validation. Throughout the analysis of each of the four cases, copious notes were taken to document the discussions which enabled the two investigators (SCN and CG) to conduct a cross-case analysis.
A document analysis matrix was developed to allow for consistency and to identify; document date and type, how obtained, content summary, and any reference that aligned with the theoretical proposition that the collective participation of FPs was evident.
After finalizing the themes, we summarised the main findings of each case into a draft report. We shared the report with each gatekeeper for verification of the findings and interpretation. This triangulation of data with the gatekeepers is consistent with Yin’s criterion of internal validity which increased our ability to capture accurate knowledge in each case (Yin, 2018). Following minor revisions, the final reports were provided to the gatekeepers of each site for dissemination within their OHTs.
Phase III: Cross-case analysis and conclusions
Subsequently, we revisited the data, both within-case and across-case, through the lens of functional organization theory. By analyzing between and across cases, we were able to understand key differences, or factors, that strengthened, or challenged, OHT development. Functional organization theory is relevant to stability and consistency related to collective decision making, all of which underpins success. Although the unit(s) of analysis (or case) does not constitute a formal ‘organization’, theoretical application is applied to the fact that ‘organization’ is not viewed as a single entity but includes multiple individuals (in this case, family physicians).
Quality of Research
Returning to Yin’s research design quality criteria, investigators remained mindful of each throughout the study.
1. Construct validity was reinforced by drawing on multiple sources of evidence (e.g. semi-structured interviews, OHT-related documents, archival documents) and also by asking gatekeepers, who were also key informants, to review the summary of results.
2. Internal validity was reinforced using triangulation techniques with multiple investigators and two coders plus the application of pattern matching logic in the cross-case analysis, seeking whether individual cases show similar outcomes in organizing for FP participation. Rival explanations were explored when results were presented and discussed by the full study team and when stakeholder reports were provided to each gatekeeper for feedback and/or confirmation.
3. External validity has been achieved using replication logic with the multiple-case method, as each case presented enough similarities as a developing OHT to enable the inquiry related to similar structures and processes.
4. Reliability has been attended to with a well-developed research design and protocol, investigator interview training and documented processes. Additionally, efforts were made to ensure sufficient data collection in each case, including a goal of half of the participants who are FPs. These components helped ensure accountability to study procedures and allowed for close replication of results across the four OHTs.
Findings
This study sought to illustrate how FPs are participating in developing OHTs, whether via a unifying structure for decision making purposes (committee, council, alliance) or employing specific processes that enabled participation. In total, 39 interviews were completed, 17 (44%) of those were with family physicians (Table 1)
Table 1: Case characteristics
Case 1
• Cohort 2, approved Nov 2020
• Geography: Rural region
• Participants: 4 FPs, 6 non-FPs
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Case 2
• Cohort 1, approved Dec 2019
• Geography: Rural/northern region
• Participants: 4 FPs, 6 non-FPs
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Case 3
• Cohort 2, approved Nov 2020
• Geography: Rural/urban mix region
• Participants: 5 FPs, 6 non-FPs
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Case 4
• Cohort 2, approved Nov 2020
• Geography: Rural/remote/northern region
• Participants: 4 FPs, 4 non-FPs
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The interviews took place between June and November 2021 and lasted between 35 and 90 minutes.
There were several shared themes among cases, and some outliers identified by within-case and cross-case analysis. Three broad themes were: 1) structure for decision-making, 2) processes related to communication and relationship-building/collaboration, and 3) challenges to FP participation (Table 2).
Table 2. Shared themes within cases
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Themes
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Case 1
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Case 2
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Case 3
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Case 4
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1.
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Structure for FP participation was viewed as valuable
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Structure pending development
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Well-defined structure in place and active participation
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Well-defined structure in place and active participation
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Discussions started related to a FP structure
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2.
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Communication with FPs a challenge
Relationship-building/collaboration pivotal to OHT development
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Not well, not “super-strong”, “horribly piecemeal”
Collaboration between FPs evident within small communities but minimal across the region
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Too much info, too little that’s relevant to FPs; consistent mechanism needed
High degree of previous collaboration through similar integration work very beneficial to OHT development and FP participation
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Strong start to FP communication but challenged by different practice models
Power imbalances between providers and OHT partners had detrimental impact on OHT development
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Communication minimal, efforts underway to create website
Minimal region-wide collaboration between FPs due to remote nature of services but some situational collaborating evident
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3.
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Challenges;
Skepticism
FP Workloads
Pandemic impact
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Some skepticism from FPs re: OHT success
Burnout and heavy workload of FPs seen as poorly understood by non-FP OHT partners
Pandemic shifted focus away from OHT work
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High degree of skepticism from FPs noted
Overworked FPs had limited their ability to participate
Pandemic response viewed as a success due to collaboration history
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Some skepticism from FPs re: government
FPs noted that Health Home model may increase the burden on them
Pandemic stalled OHT development
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Minimal skepticism from FPs noted; enthusiasm instead for OHT work
Workload for FPs exacerbated by need for multiple roles in rural regions
Pandemic pushed back all OHT activities; late start in securing admin lead, digital presence
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Outliers represent actions or outcomes which either enabled FP participation or otherwise made their participation even more challenging and were evident in some of the shared themes (Table 3).
Table 3: Cross-Case Analysis: exploring outliers within themes
1.
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Structures for decision making
A strong emphasis on establishing a governance structure for FPs was clear in 2 cases. In both, FPs were participating at governance and community levels with one making a significant effort to ensure representation on all working groups
In one case FP participation was primarily at the governance level
In still another case, there were no FPs participating in any role.
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2.
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Communication successes
Face-to-face communication was highly favoured in 1 case, viewed as respectful by FPs which resulted in more participation by FPs
FPs in rural communities that practiced in hospitals frequently received OHT updates from the Medical Advisory Committee which kept them informed
Relationship-building/collaboration
In 1 case, relationships that pre-existed before the OHT allowed this community to ramp up quickly as an OHT
In another case, history played a detrimental role as power imbalances and challenges in partnering made engaging with FPs difficult.
In one case engagement with the large First Nations population highlighted the need for cultural safety training for all partners
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Within-case analysis results
This section details the findings of the within-case analysis that was conducted. Each case was analyzed to understand physician participation within those communities.
1) Structure for decision making
In each case, the need to have a formalized structure for FPs (committee, council) was seen as a valuable mechanism for communication and decision-making.
“On the primary care side, they have to be able to organize, to speak with one voice so you’re not getting six different answers from six different practices”(nonFP).
2) Processes
Communication strategies and relationship-building with FPs were priorities to enable FP participation.
Communication
Communication with FPs was a challenge in all cases. Email was the method used most often by OHT administrators for sharing information although the least preferred by busy FPs and easily overlooked “when you get 5 billion emails all the time”(FP). Despite a lack of time, FPs identified that, where possible, in-person communication was the best way to deliver information “because a face-to-face meeting is worth a million times an email in your inbox”(FP). Meetings that took place after work hours enabled FP participation as it would not take them away from their busy workday, however, after hours meetings were few and far between. Preliminary presentations were made to the primary care sector at the time of OHT approval and/or application in most cases. This was seen as a good opportunity for generating dialogue with FPs but did not continue once the OHT was approved.
Relationship building/collaboration
Partnerships are dependent upon relationships. In all cases, relationships played a key role in OHT development. Building trust between providers and organizations takes time and previous collaborative attempts in a community can either amplify good working relationships or resurrect previous clashes that hinder movement. In three of the four cases FPs referred to “some historical stuff between hospitals and community”(non-FP) which impeded progress.
Building an integrated system of care requires commitment yet participation to date has been voluntary which limited the urgency to participate. FPs expressed that there was “no impetus to actually force anybody to collaborate” and people came to the OHT planning table “because they think it’s the right thing to do”(FP).
A history of collaboration (or absence of such) among FPs, and between FPs and other providers or organizations significantly influenced their participation, support for, and value of the OHT. A history of collaboration was impacted by various factors. Geographical factors could lead to “a lot of openness to sharing resources and ideas” (non-FP) due to shared needs and resources but also lead to longstanding divides for the same reasons. Differences in funding models led some communities and FPs to be more equipped to participate in system integration whereas others that were under-resourced felt less supported to do so. Other cases expressed concerns over “internal politics around various physician groups” (non-FP) which has led to siloed communities. The turnover of previous system integration initiatives, like the LHINs, has also fostered a lack of trust amongst physicians to participate.
4) Challenges to FP participation
Skepticism
Skeptics were plentiful in all cases, primarily among FPs. Previous government initiatives limited their degree of enthusiasm for participating in OHTs. Several participants described their hesitation as “having been at this rodeo before” leading them to wonder “is this just the repackaged, newest flavor from the government?”(FP). This was particularly evident among those that had been in practice long enough to see several government-funded initiatives come and go with little to show for them, diagnosing it as the “LHIN hangover”(FP).
Burnout and workload
High levels of burnout among family physicians are evident everywhere. FPs expressed that “we’re asked to do everything by everybody for everyone”(FP). Most FPs are already working extremely long days which extend into weekends and face multiple workplace stressors, severely limiting their capacity to take on more. FPs identified that non-FP members of the OHT were limited in their understanding of a FP’s workday, evidenced by “constantly having meetings at 2 p.m. in the middle of the day: you’ll never get doctors that come out”(FP). Workload was also exacerbated in rural regions due to multiple roles as “they have emergency room shifts to cover for a week and then they’re doing inpatient care for their patients that are in hospital and then they’re still running a primary care practice” (non-FP).
COVID-19 pandemic
The need to shift priorities from March 2020 and beyond for everyone in healthcare was enormous, non-stop, and stressful, and OHT development stalled in all cases. “It’s unfortunate the way the timing of all of this played out because there was some initial momentum and then things were shut right down”
Despite having to pivot away from OHT development to deal with the pandemic, the shift for FPs to work together to operate vaccination clinics and the continual updates about changes in public health policy required them to work more closely with one another and was seen as beneficial in building relationships. FPs that previously had rarely communicated with one another were now on group zoom calls frequently.
“it’s really enabled us to have a strong and robust COVID response. So really integrated approach initially with the assessment centres between the Family Health Team staff and the primary care physicians doing the bulk of the testing. That kind of evolved into just being ready and able to work collaboratively by the time that the vaccine started coming” (non-FP).
Cross-case analysis results
This section details the findings of the cross-case analysis that was completed following the within-case analysis. We reviewed the themes and found some outliers or examples of unique approaches that significantly impacted OHT development.
1) Structures for decision-making
Although each case acknowledged the value of a structure to enable collective action by FPs, varying levels of effort were invested into establishing this structure. Two of the cases were much further advanced in this journey. In both cases, an existing or pre-existing committee was strengthened, primarily in relation to OHT activities. These committees had terms of reference, transparent governance structures, and decision-making frameworks that provided for fair representation among all FPs in the region regardless of practice model. Meetings were held with regular frequency and consistently high attendance noted. In one of these cases, a worthy effort was also made to ensure the inclusion of FPs as co-leads on all project-specific groups which increased connection between decision-making and action.
In the other two cases the dialogue about resurrecting a previous regional planning table to facilitate family physician’s collective decision making was underway. In one, a distinct clarification about the purpose of the newly formed group structure was made to emphasize that a physician-centric committee would work “alongside the OHT but not under the OHT”(FP) and FPs made it clear that “there are other issues and conversations that would benefit from collective dialogue via such a structure beyond OHT-specific items”(FP). In the other case there was no evidence of a previous structural model to build upon and, while viewed by OHT leads as valuable, this was largely premised on perceived expectations of the ministry, with no evidence that FPs were yet engaged in planning. Nebulous expectations from the province frustrated leadership “It’s usually easier to reengineer a system by collaborative work and then some sort of direction. There’s very little direction here”(non-FP).
2. Processes
Communication
Some key successes, along with noted failures were evident; the assessment of communication strategies varied considerably between FPs and non-FPs. This was particularly evident in one case where, according to one FP, communication with OHT leads was “not ‘super-strong” and “horribly piecemeal” while we heard from non-FPs that “we are well connected with our physicians” (non-FP).
In another case, FPs acknowledged occasional face-to-face meetings with an OHT physician leader which went a long way to engaging community FPs in OHT development. This reflection in a different case by a FP illustrated just how valuable in-person communication was.
“I think in a perfect world someone would sit down with us in a face-to-face meeting and explain to us what this OHT is going to look like and how the vision is of how primary care is going to be involved. I don’t feel like that’s happened” (FP)
In one of the cases there was a noted failure to meaningfully engage physicians in consultation around the OHT:
“That’s been the feel, on the ground, is the opportunity for consultation has largely been survey-based, passive, do this survey for 20 minutes and give us your opinion. As a primary care practitioner the starting point needed to be consultation on the ground, to speak to the clinicians on the ground before any bigger conversation happened about who we hire as admin support and which communities we include” (FP).
Relationship-building/collaboration
In two cases OHTs were led, or co-led by a competent, respected FP with pre-existing relationships in the community. This was viewed as a key factor for success in each of these two cases. One FP noted, “there really are the key physicians who have done a lot of the work up front, but then they can pull in other physicians in the offices” (non-FP).
In one case, inequities between OHT partners and perceived power imbalances challenged progress. “Family physicians need to be treated fairly as equal partners”(FP) Distrust among some community partners prevented some FPs from wanting to participate; the existence of a power struggle was clear. We heard that “it’s the specialists and the surgeons that are seen as the top ranked physicians and the family physicians and practices are local yokels… a flip-flop that needs to happen where the specialists and the surgeons are supporting the family physicians because that’s where people want to be”(FP).
The history of collaboration varied amongst the cases. Only one case reported a strong history of collaboration with previous attempts at system integration. As a result, this facilitated a smoother transition into the OHT model, “because of its preliminary work which started, […] that was very similar to an OHT, where there was strong collaboration” (non-FP).
The rest of the cases were characterized by sporadic, grassroots-led instances of collaboration. Prior to OHT formation, two cases noted strong grassroots, spontaneous collaboration between some FPs, organizations, or communities. However, a significant divide was found between other FPs in the same cases due to differences in resources, funding models, and hospital presence. This has led to low incentive in collaboration and minimal trust amongst FPs..