By Oona Hayes
We are facing significant, complex problems in health care, and we know there are no simple answers. Quality improvement science acknowledges that changing one part of a system will destabilize other parts. We must define and refine the problems we aim to fix with system changes to provide individuals with clear goals and the desire for change. Clear goals allow for monitoring progress, adjusting as necessary, and assessing other impacts of change efforts.
There is an urgent need to address the primary care crisis, and organizations such as the Family Practice Services Committee (FPSC) are working with the Ministry of Health to promote system change. My last MD’s Corner article outlines two crucial points that bear repeating. The province of B.C. is amidst a massive primary care change management exercise, and organizational change can only change when individuals change. Organizations must guide individuals through that change. I wrote that article feeling genuine distress that many physician colleagues are either unaware or unengaged in the change management efforts in primary care that directly affect them and their patients.
How can we have system change without successful individual change?
How can the individual family physicians, who provide most of the longitudinal primary care in this province, want to change how they work?
The FSPC has outlined their goals for system change:
- Increase access to appropriate, comprehensive, quality primary health care for each community.
- Improve support for patients, particularly vulnerable patients, through enhanced and simplified linkages between providers.
- Contribute to building a more effective, efficient, and sustainable health care system in order to increase access to primary care, and to ensure patients can have a long-term relationship with a primary care provider, usually a family doctor.
- Retain and attract family doctors and teams to work together in healthy and vibrant work environments.
Their website describes the functional units and enablers of this goal, including Patient Medical Homes, Primary Care Networks, Team-Based Care, Panel Management and Clinical Networks.
It’s hard to succinctly and reliably define what the FPSC’s high-level goals mean to another family physician. When engaging physicians in change efforts, they need help understanding or do not necessarily want what is hard. I don’t write this to discount the vision and goals of the FPSC but to underscore the need for more granular goals and direction. Acknowledging the real and perceived objections to the vision and meaningfully addressing these is also critical to the ongoing cooperation of individuals.
The FPSC’s recent PCN Governance refresh reflects their commitment to listening to and addressing concerns. It asks communities to work collaboratively to understand and respond to primary care needs within the Primary Care Network model. It gives responsibility to the Divisions of Family Practice and a physician convener. The refresh underscores that there cannot be a one-size-fits-all solution to the pain points experienced by different communities and clinicians around the province. This PCN refresh will help communities (including the community’s physicians and other health care providers) define their goals for success, considering the potential impacts on different parts of the system. Clear goals for community success automatically help with accountability and reporting requirements, which the Health Authorities will continue to hold.
Physicians are used to reacting to the needs of individual patients presenting for care. Family physicians are so busy with everyday practice that they don’t have time to consider different ways of working. Physicians have been told that the benefit of investing time and effort in team-based care will pay off in the future with a better quality of life and more work satisfaction but may not trust this will be the case. One of the goals of system change is to ensure more patients are getting appropriate care, whether it’s for acute or chronic issues, as well as to promote disease prevention and screening. A key part of enabling system change will be empowering and guiding family physicians to consider their practice’s and community populations’ strengths and vulnerabilities that affect the need for screening, preventive care, disease management, and to act on this information, without burdening them more. Whereas some physicians might need help understanding the rationale for panel management, it can provoke interesting insights and questions that inform dimensions of the quality of care in a community. For example, who is at risk of having a diabetic foot ulcer and potentially an amputation within the next decade? How would it impact your community if a foot care specialist for targeted preventive care saw the people at risk for amputation? I see a natural synergy between using the HDC Discover tool and increased collaborative care, while working towards the quintuple aim of healthcare, which includes provider satisfaction. HDC Discover measures capture details about the vulnerabilities and strengths of practice and aggregate populations, as well as informing several dimensions of quality, as described in the HQBC Health Quality Matrix. HDC Discover can help inform how PCNs deploy resources (providing a snapshot of the needs of different practices or groups within the community) and can then be used to monitor the effectiveness of interventions. Our Bright Spots articles describe some of the impacts of HDC Discover’s use and show the value of data to support patients, clinicians and communities.
One way to get colleagues more involved in primary care change efforts will be to communicate more detail and more awareness about the goals of change. If our North Star is team-based integrated care, we must be able to describe what success could look like. What does success look like for the different constituents – patients and their caregivers, providers and the system? Just like our patients benefit from setting brief action plans around health goals, we will strengthen physicians’ engagement by increasing understanding and translating what these system changes could look like at an individual level. Tracking data from different sources (e.g. patient satisfaction surveys, HDC Discover, physician satisfaction and engagement, number of new patients attached, number of patients seen by the team) will show the collective impact of the work and hopefully sustain and reinforce change. We need to translate high level vision for system change into actions that move us closer to the goal of realizing the vision.