The implementation of quality improvement facilitators in primary care settings in Quebec: a case study (preprint)

Background Quality improvement (QI) facilitators were integrated into Quebec’s university affiliated primary care practices. After an evaluation demonstrated the QI facilitators’ key role in implementing a QI culture, the Ministry of Health and Social Services decided to test the intervention in non-academic primary care practices with a one-year pilot project in one regional health organization. This study aims to understand the role and implementation of QI facilitators in non-academic primary care practices, as well as to highlight levers and barriers to their contribution.Methodology A single embedded case study was used to understand the implementation of QI facilitators. Led as an organization participatory research, the conduct of this study involved knowledge users. The Conceptual Framework for Implementation Research was used for the development of the interview guide and data analysis. We used two sources of data: 1) with the support of knowledge users, we obtained relevant documents about the QI facilitators’ role, the governance and planned implementation strategies (n = 17); 2) we conducted 19 semi-structured interviews with QI facilitators (n = 6), managers (n = 7) and physicians (n = 6) that were involved in the implementation of the pilot. Directed content analysis, triangulated writing analytics memos from documentation, was used to understand the QI facilitators’ role enactment and contribution, as well as their integration in the COVID-19 context.Results All participants had a positive perception of the QI facilitators’ role on bringing a QI culture and on the implementation of primary care projects. Three explanatory factors could explain the barriers and levers to the implementation of QI facilitators. Being decentralized was considered as enabling a more personalized approach, in which QI facilitators could better respond to their respective territory’s needs. QI facilitators worked under a co-management structure that included the clinics’ medical directors and the territorial managers. This structure was seen as an enabler to the QI facilitators’ integration and to their contributions in coordinating projects meeting provincial guidelines in the COVID-19 context.Conclusion The implementation of QI facilitators was positive for non-academic primary care practices. This study suggests elements for public institutions and managers to consider in the implementation of such QI facilitators in primary care practices.

COVID-19 – An Opportunity to Improve Access to Primary Care Through Organizational Innovations? (preprint)

Background: COVID-19 catalyzed a rapid and substantial reorganization of primary care, accelerating the spread of existing strategies and fostering a proliferation of innovations. Access to primary care is an essential component of a health care system, particularly during a pandemic. We describe organizational innovations aiming to improve access to primary care and related contextual changes, during the first year of the COVID-19 pandemic in two Canadian provinces, Quebec and Nova Scotia. Methods: We conducted a multiple case studies, based on 63 semi-structured interviews (n=33 in Quebec, n=30 in Nova Scotia) conducted between October 2020 and May 2021 and a review of related internal documents from both jurisdictions. We recruited a diverse range of provincial and regional stakeholders (e.g., policymakers, decision-makers, family physicians, nurses) involved in reorganizing primary care during COVID-19 using purposeful sampling (e.g., based on role, region). Interviews were transcribed verbatim and thematic analysis was conducted in NVivo12. Emerging results were discussed by team members to identify salient themes and organized into logic models. Results: We identified and analyzed six organizational innovations. Four of these - centralized public online booking systems, centralized access centers for unattached patients, and interim primary care clinics for unattached patients and community connector to health and social services for older adults – pre-dated COVID-19 but were accelerated by the pandemic context. The remaining two innovations were created to specifically address pandemic-related needs: COVID-19 hotlines and COVID dedicated primary healthcare clinics. Innovation spread and proliferation was influenced by several factors such as a strengthened sense of community amongst providers, decreased patient demand at the beginning of the first wave, renewed policy and provider interest in population-wide access (versus attachment of patients only), suspended performance targets (e.g., continuity ≥80%) in Quebec, in modality of care delivery, modified fee codes, and greater regional flexibility to implement tailored innovations. Conclusion: COVID-19 accelerated the uptake and creation of organizational innovations to potentially improve access to primary healthcare, removing, at least temporarily, certain longstanding barriers. Many stakeholders believed this reorganization would have positive impacts on access to primary care after COVID-19. Further studies should analyze the effectiveness and sustainability of innovations adapted, developed, and implemented during the COVID-19 pandemic.