Assessing the evolution of primary healthcare organizations and their performance (2005-2010) in two regions of Québec province: Montréal and Montérégie

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The Canadian healthcare system is currently experiencing important organizational transformations through the reform of primary healthcare (PHC). These reforms vary in scope but share a common feature of proposing the transformation of PHC organizations by implementing new models of PHC organization. These models vary in their performance with respect to client affiliation, utilization of services, experience of care and perceived outcomes of care. In early 2005 we conducted a study in the two most populous regions of Quebec province (Montreal and Montérégie) which assessed the association between prevailing models of primary healthcare (PHC) and population-level experience of care. The goal of the present research project is to track the evolution of PHC organizational models and their relative performance through the reform process (from 2005 until 2010) and to assess factors at the organizational and contextual levels that are associated with the transformation of PHC organizations and their performance. This study will consist of three interrelated surveys, hierarchically nested. The first survey is a population-based survey of randomly-selected adults from two populous regions in the province of Quebec. This survey will assess the current affiliation of people with PHC organizations, their level of utilization of healthcare services, attributes of their experience of care, reception of preventive and curative services and perception of unmet needs for care. The second survey is an organizational survey of PHC organizations assessing aspects related to their vision, organizational structure, level of resources, and clinical practice characteristics. This information will serve to develop a taxonomy of organizations using a mixed methods approach of factorial analysis and principal component analysis. The third survey is an assessment of the organizational context in which PHC organizations are evolving. The five year prospective period will serve as a natural experiment to assess contextual and organizational factors (in 2005) associated with migration of PHC organizational models into new forms or models (in 2010) and assess the impact of this evolution on the performance of PHC. The results of this study will shed light on changes brought about in the organization of PHC and on factors associated with these changes.

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Available from: Jean-Frederic Levesque
STUD Y PROT O C O L Open Access
Assessing the evolution of primary healthcare
organizations and their performance (2005-2010)
in two regions of Québec province: Montréal and
Jean-Frédéric Levesque
, Raynald Pineault
, Sylvie Provost
, Pierre Tousignant
, Audrey Couture
Roxane Borgès Da Silva
, Mylaine Breton
Background: The Canadian healthcare system is currently experiencing important organizational transformations
through the reform of primary healthcare (PHC). These reforms vary in scope but share a common feature of
proposing the transformation of PHC organizations by implementing new models of PHC organization. These
models vary in their performance with respect to client affiliation, utilization of service s, experience of care and
perceived outcomes of care.
Objectives: In early 2005 we conducted a study in the two most populous regions of Quebec province (Montreal
and Montérégie) which assessed the association between prevailing models of primary healthcare (PHC) and
population-level experience of care. The goal of the present research project is to track the evolution of PHC
organizational models and their relative performance through the reform process (from 2005 until 2010) and to
assess factors at the organiza tional and contextual levels that are associ ated with the transformation of PHC
organizations and their performance.
Methods/Design: This study will consist of three interrelated surveys, hierarchically nested. The first survey is a
population-based survey of randomly-selected adults from two populous regions in the province of Quebec. This
survey wi ll assess the current affiliation of people with PHC organizations, their level of utilization of healthcare
services, attributes of their experience of care, reception of preventive and curative services and perception of
unmet needs for care. The second survey is an organizational survey of PHC org anizations assessing aspects related
to their vision, organizational structure, level of resour ces, and clinical practi ce characteristics. This information will
serve to develop a taxonomy of organizations using a mixe d methods approach of factorial analysis and principal
component analysis. The third survey is an assessment of the organizational context in which PHC organizations
are evolving. The five year prospective period will serve as a natural experiment to assess contextual and
organizational factors (in 2005) associated with migration of PHC organizational models into new forms or models
(in 2010) and assess the impact of this evolution on the performance of PHC.
Discussion: The results of this study will shed light on changes brought about in the organization of PHC and on
factors associated with these changes.
* Correspondence:
Institut national de santé publique du Québec, Québec, Canada
Full list of author information is available at the end of the article
Levesque et al. BMC Family Practice 2010, 11:95
© 2010 Levesque et al; licensee BioMed Central Ltd. This is an Open Access article distributed unde r the terms of the Creative
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Page 1
In early 2005 we conducted a study in the two most
populous regions of Québecprovince(Montréaland
Montérégie) which examined the association between
prevailing models of primary healthcare (PHC) and
population-level experience of care [1]. This study fol-
lowed the launching of two reform policy initiatives by
the Québecs Ministry of Health and Social Services: the
creation of Family M edicine Groups (FMG) and the
establishment of Local Services Networks (Local Net-
works) under the governance of Health and Social Ser-
vices Centres [2]. FMGs were established to increase
accessibility and continuity of care while Health and
Social Services Centres (Local Centres) aimed at better
coordinating and integrating service s by creating territo-
rially-defin ed Loc al Net works. Although these policie s
were respectively proposed in 2002 and 2004, implemen-
tation was only b egun, for the most part, in 2005, coin-
ciding with the conduction of the aforementioned study.
Four years later both reforms are well-established, and
the question arises of how PHC models have evolved,
what factors have promoted the evolution of PHC organi-
zations, and how this evolution has translated into mea-
surable effects at the population level. The decision-
make rs of the two regions have approached our research
team to explore these questions. The study we conducted
at the early phase of implementation of these reforms will
provide us with a reference point for assessing the evolu-
tion of PHC organizations over a five year period. The
studys goal is to assess the evolution of PHC organizations
through the reform, identify factors associated with this
evolution, an d eval uate its association with the perfor-
mance o f PHC organizations and Local Networks. The
knowledge generated by this study will h elp to furt her
PHC reorganization efforts in various jurisdictions by bet-
ter understanding factors that can promote organizational
change and by bette r understanding the i mpact of t his
change on population-level experience of care.
Our project team includes researchers and decision-
makers engaged in the co-production of relevant infor-
mation in order to guide PHC reforms and optimize
PHC service provision. B y providing sound evidence for
decision-makers and clinicians regarding factors related
to the transformation of PHC organizations, we aim at
supporting t he implementation of PHC reform efforts
and thus improve the performance of the healthcare sys-
tem in addressing healthcare needs of Canadians.
The current reform of PHC organization in Québec
Health and Social Service s Centres (Local Centres) have
been created by law [3], merging acute care hospitals,
long-term ca re hospitals and Local Communit y Services
Centres (CLSC) on a geographical basis. Their main
objective is to lead to the imple mentatio n of Local Net-
works and to increase colla boration among PHC organi-
zations through the creation of these networks [4]. The
Local Networks are composed not only of the facilities
merged under Local Centres but also of all other health
and social services providers, including privately owned
medical clinics. There are 95 Local Centres and Net-
works in Québec, 12 in Montréal and 11 in Montérégie.
Local Centres and Networks vary in composition since
some have acute care hospitals while others dont. In
addition, Local Centres benefit from a large autonomy
in the planning and organization of services and
The FMG policy consists most ly in develop ing a con-
tractual agreement between PHC clinics and the provincial
government. PHC organizations receive complementary
funding in exchange of complying with certain organ iza-
tional requirements identified in the FMG policy (e.g.
extended opening hours). In addition, each FMG has a
contractual agreement with Local Centres that enables
them to benefit from the presence of a nurse. A FMG con-
sists of 6 to 10 physicians who work together with nurses
to provide services for registered members of the group,
on a non-geographical basis (usually around 10,000 to
20,000 people per FMG). A FMG provides services both
by appointment and on a walk-in basis. It aims at being
accessible 24 hours a day, 7 days a week, through opening
hours that extend into the evening (until 9:00 p.m.) and
weekends (at least 4 hours), and through a regional on-call
system (Info Health line) for vulnerable patients when the
clinic is closed. The target established at the start of the
of March 2009, there were 181 accredited FMGs in
Québec, 42 in Montréal and 55 in Montérégie.
A complementary model of organization currently
being implemented in the regions under study is the Net-
work Clinic. These clinical settings are more specifically
targeted to ongoing and integrated management of cli-
ents, particularly those considered vulnerable,andto
provide access to basic technical support, such as radiol-
ogy, blood tests, and specialists [5]. Their creation was
initiated by the Montréal Regional Health Agency as a
complement to FMGs, in response to requests by the
regional medical association. A clinic can concurrently
have the status of FMG and Network Clinic, thus benefit-
ing from two sources of funding. As of March 2009, there
were 36 Network Clinics in Montréal, among which
twelve had both FMG and Network Clinic status.
A recently completed research project
We recently completed the research project Accessibility
and Continuity of Care: A Study of PHC in Québec which
was conducted in two regions in the provinceMontr éal
Levesque et al. BMC Family Practice 2010, 11:95
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Page 2
and Montérégie [1,6]. It looked at organizational models of
primary healthcare and their influence on accessibility and
use of health services by the population, as well as the
experience of u sers of t hese services. The main objective
of the study was to identify organizational models of PHC
that are best adapted and most likely to meet the popula-
tions needs and expectations. The research included three
components: 1) a survey of the population designed to
measure utilisation of health services as well as users per-
ception of the accessibility, continuity, comprehensiveness,
responsiveness and perceived results of services received
[7]; 2) a study of PHC clinics that aimed to describe the
PHC organ ization models in the regions studied [8]; 3) a
contextual analysis that sought to describe Local Networks
[9]. We identified five models of PHC organizations. Four
were professional models (one was a single-provider
model, one was a contact model (walk-in clinics), and two
models were coo rdination models, one being integrated
and the other non-integrated in the overall healthcare sys-
tem), while one was a community-oriented model. Overall,
the integrated coordination and single provider models
were associated with better patient experience of care, fol-
lowed by the community-oriented model. The contact
professional model was associated with the worst experi-
ence of care across all measures [1].
What does the literature tell us about PHC organizations?
Recent studies have focused on models of care, or ways
to organ ize clinical services, that promote more accessi-
ble, coordinated, patient-centered care with emphasis on
health promotion and disease prevention [ 10,11]. Mod-
els of care such as the medical home and the chronic
care models, among the most often cited, have shown a
great potential for achieving such results [11-15]. How-
ever, researchers have paid much less attention to the
structure and processes developed at the organizational
level, in which these models of care can be implemented
and which require certain organizational conditions for
their successful implementation [16].
Several organizational attributes have been associated
with a better performance of PHC organizations [17].
For example, physician payment modalities have a deter-
mining effect on their practice. Fee-for service is asso-
ciated with greater productivity but less continuity of
care when contrasted with per capita prepayment which
encourages more continuity and prevention [18,19].
Although it is possible to identify the effect of individual
attributes of organizations on various process or out-
come indicators, it remains more difficult to understand
how these attributes relate to each other in actual orga-
nizations and systems. However, studies that focused on
comparisons betw een different types of P HC organiza-
tions or systems (e.g. Kaiser or Veterans Administration)
have provided enlightening results [20,21]. Although
differences between types of organizations could be due
to specific organizational a ttributes, understanding the
effect of various organizational c haracteristics in a sys-
temic perspective remains a challenge [22] . Hence, there
is a need for a more holistic view in the study of health-
care organizations and systems.
The configurational approach, which views an organi-
zation as a whole rather than a set of independent attri-
butes, is instructive in this regard [23,24]. This view
seems to best meet the representation held by decision-
makers of what an organization really is [25]. In essence,
a configurational approach suggests that organizations
are best understood as clusters of interconnected struc-
tures and practices, rather than as modular or loosely
coupled entities whose components can be understood in
isolation [26]. Configurations are represented in typolo-
gies developed conceptually or captured in taxonomies
derived emp irically [23]. Taxonomies are generally
derived from cluster-analytic methods, thus forcing simi-
lar organizations to form h omogeneous groups [26-29].
A complementary measure is a deviation score [30]. In
this case, the researcher defines an ideal-type of attri-
butes based on theoretical considerations and then calcu-
lates a score of conformity to this ideal-type, based on
empirical observations [26].
One way to conceptualize various organizational mod-
els derived from the configurational approach is to con-
sider them as a system for organized action defined by
four sets of attributes: vision, resources, structure and
practices [31]. As it applies to PHC organizations, vision
corresponds to the values and repre sentations shared by
the actors [1,16]. Structure refers to the interaction and
regulation among actors, such as interprofessional colla-
boration, and governance. Resources are defined by the
type and level of various resources (human and mate-
rial) and their arrangement. Finally, practices comprise
mechanisms for offering services, deve loping multidisci-
plinarity and ensuring follow-up of patients.
This approach has been used in our previous work. In
a recent policy syn thesis, we derived a taxonomy of four
models: two professional and two community models
[16]. Following the same methodological approach, but
using data on PHC organizations in t wo regions, we
derived another taxonomy that is very consistent with
the policy synthesis. We found only one community
model, but four professional ones: the single provider,
the contact, the coordination and the coordinati on i nte-
grated [1]. In order to contrast models from a normative
standpoint, we also constructed an index of conformity
to an ideal-type, based on the literature on group prac-
tice and on the various policy documents on new emer-
ging forms of PHC organizations (such as the FMG).
Not only d o these models or archetypes provide an
holistic view of an organization, compared to other
Levesque et al. BMC Family Practice 2010, 11:95
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Page 3
forms of organizations derived from the same taxonomy,
but they also permit the assessment of change over
time, when an organization passes from one archetype
to another [23,25,30]. Comparing archetypes or models
specific organizations belong to at different points in
time is thus a sensitive measure of organizational
What does the literature tell us about factors associated
with PHC organizational change?
Institutional t heory of organization has become widely
used to explain organizational c hange [32-34]. Accord-
ing to this theory, the environment exerts a determining
influence on organizations that tend to take a similar
form within an organizational field (the sharing of com-
mon norms and values) le ading to a ce rtain degree of
homogeneit y called isomorphism [32,35,36]. In the pub-
lic sector, geographically defined territories such as
Local Networks can exert such an influence [37,38].
Environmental pressures exerted on organizations a re
of three types: coercive, normative and mimetic [36].
Coercive pressures refer to laws, r egulations and state
policies. As Scott [38] points out, the state has the defi-
nitive ability to apply these kinds of pressures either by
law or by introducing strong incentives in fina ncing
publicly-supported organizations. The two measures
introduced by the Québec Government to create FMGs
and Local Centres are essentially of this kind. Normative
pressures are very prevalent in an environment of pro-
fessional organizations such as the healthcare system.
They refer to values and norms held by professional
associations that tend to permeate organizational
boundaries [33,39,40]. Hence, loc al professional associa-
tions and leaders have normative influences on PHC
organizations through their links with professionals in
these organizations [38,39]. Finally, mimetic pressures
stem from organizations considered as examples by
others that tend to imitate them. F MGs and Network
Clinics can be seen by other clinics as model PHC orga-
nizations, thus generating mimetic pressures on these
Although organizati ons within a n organizational field
tend to converge to some form of isomorphism in
response to these pressures, the y do not react exactly in
the same manner [38]. There are intrinsic characteristics
of organizations mainly related to dominant values held
by their professionals and the role played by influential
actors that make them more or less sensitive and recep-
tive to these pressures [38]. For instance, clinics that
already collaborate with other clinics may have a higher
propensity to respond to mimetic or normative pres-
sures [38].
These th ree types of pressure do not necessarily act in
the same dire ction and they can even neutralize each
others i nfluence. This was the case i n the implementa-
tion of CLSCs (Local Community Services Centres) in
Québec. The Governme nt policy aimed to establish a
public health and social services organization (coercive
pressure) was opposed by professional medical associa-
tions which encouraged their members not to practice
in CLSCs (normative pr essure) and reactively developed
a network of privately owned group practice clinics
(mimetic pressure) [4,41]. The opposition and reaction
of the medical organized medicine to the CLSC project
was a major obstacle in making CLSC the point of entry
into the syst em. This illustrates the point that in order
to yield maximum organizational change these pressures
need to align in the same direction.
What does the literature tell us about the effects of PHC
organizations in the context of reforms?
The contribution of PHC in achieving health objectives
has been largely documented [42,43]. Systems based upon
well-organized PHC are better performing in many
aspects, namely experience of care (continuity, accessibil-
ity, comprehensiveness, responsiveness) [42,44]. They also
report a more appropriate use of services, as reflected by a
lower use of hospital and emergency care [45].
Reforms of PHC organizations and local organization
of healthcare services have been the subject of various
evaluative studies in Canada [46]. Studies in Québec,
Ontario, Manitoba and British Columbia have high-
lighted the positive impact of new forms of PHC organi-
zations integrating desirabl e attributes of experience of
care [7,41,47-52]. Studies have focused on understanding
the process of organizational changes using a case study
approach [16,53], linking experience of care and use of
services pro vided by a limited number of organizations
[48,54], using administrative data files or population sur-
veys. N one of these studies have nominally linked ser-
vices users with their regular source of care [55-57].
Overall, these studies have highlighted some benefits of
emerging models of PHC in various provinces, with
community-oriented models and those promoting coor-
dination of care showing the best results regarding t he
experience of care of patients and regarding prof essional
collaboration and satisfaction.
The gap in knowledge and need for evaluating
PHC reforms
Ongoing or recently completed studies in Québec fo cus
on various aspects of organizational performance
[1,48,53]. One study explored factors associated with the
implementation of FMGs [53]. A multiple case study
approach found a positive association between nurse-
physician collaboration and experience of care [58]. An
ongoing study using a cross-sectional design is looking
at the relationship between types of PHC organization s
Levesque et al. BMC Family Practice 2010, 11:95
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Page 4
and experience and quality of care [59]. A study cur-
rently underway adopts a longitudinal p erspective to
look at the implementation of Local Centres and the
impact on utilization and experience of care [60].
To our knowledge, no studies have assessed the evolu-
tion of PHC organizational models, identifying factors
that can explain changes, and their impact on popula-
tion-level indicators. In addit ion, we did not find studies
that have assessed the impact of PHC reforms on the
level of inter-organizat ional collaboratio n. Our st udy
includes all PHC organizations in two large regions, a
sample of the population with representativeness at t he
Local Network level and nominal linkage with the regu-
lar source of care. This evaluation of t he evolution of
models of PHC and of its population-level impact is
required to guide the continuatio n and completion o f
the PHC reform and assess the improvement in capacity
to respond to needs and expectations of populations.
Such knowledge is crucial given the difficulties of
reforming PHC in pluralistic contexts, such as Canada,
and the relatively high costs that such reform demands.
Decision-makers need to understand what promotes
organizational change and how change and its benefits
may be sustained.
Conceptual framework
Our conceptual framework is presented in figure 1.
According to this framework, organizational models
(OM) of PHC and the inter-organizational collab oration
(OC) between PHC organizations influence the organi-
zati onal per formance (OP) of PHC systems. In addition,
certain factors have an impact on the evolution of PHC
organizational models and on inter-organizational
collaboration through a period of transformation (Time
1 and 2). These factors relate both to the policies estab-
lished by the Governments and to more implicit organi-
zational environments.
The implementation of Local Centres and Networks is
seen as exerting a coercive influence o n the evolution of
PHC organizations. We expect the integrating influence
of Local Centres will increase networking as expressed
by inter-organizational collaboration among all organiza-
tions within the territory. Specific interventions or regu-
lations can in fact influence the ways PHC settings
organize various aspects of care. Examples of such inter-
ventions can include the funding of specific initiatives
by local health authorities, development of specific orga-
nizational projects under the impetus of coordinating
bodies or modification of relationships between organi-
zations because of restructuring services at various levels
of Local Centres and Net works. The int roduction of a
new organization policy has a direct effect on the imple-
mentation of e merging forms of PHC such as FMGs
through explicit policies aimed at promoting change in
the way care is organized. The implementation of new
forms of organizations can also have a mimetic influ-
ence on the other forms of PHC organizations and the
inter-organizational collaborations in place.
In addition to these contextual influences, some char-
acteristics and attributes of PHC organizations make
them proactive or more receptive toward s chang e. These
attributes can be related to the presence of a designated
team leader, or their organizational culture (e.g. concor-
dance between dominant organizational values and cur-
rent proposals of reform). Professional influence relates
to the presence of lea ders and professional or ganizations
Implementation of local health centres/networks
(coercive influence)
Implementation of new forms of PHC
(policy - mimetic influence)
Receptivity of
normative influence
Evolution of inter-
organizational collaboration
Evolution of organizational
Evolution of organizational
Figure 1 Conceptual framework.
Levesque et al. BMC Family Practice 2010, 11:95
Page 5 of 13
Page 5
that apply pressure on PHC organizations towards
accepting or o pposing changes. These influences include
elements such as the official position of medical repre-
sentatives regarding specific policies o r the pr esence of a
local champion promoting a specific model of PHC
These changes are expected to translate into an
increased organizational performance at two levels: first,
at the level of the clientele of these organizations and
second at the level of the populations of each Local Net-
work. We use performance here in a very broad sense to
include various indicators of e ffects of PHC orga niza-
tions [61]. We expect that change towards new forms of
organizations at the level of Local Networks will be
associated with improved population coverage (e.g.
affiliation with regular sources of care and unmet needs
for care), process of care (utilisation of services and
patients experience of care such as accessibility, conti-
nuity, comprehensiveness, responsiveness) and outcomes
of care (e.g. perceived results of care, reception of pre-
ventive services, preventable hospitalizations an d emer-
gency room consultations) (see Additional file 1 for
details of measures).
Study objectives
The goal of this research project is t o understand the
evolution of PHC organizational models and their rela-
tive performance through the process of PHC reform,
and assess factors, at the organizational and contextual
levels, associated with the transformation of PHC orga-
nizations and their perform ance. More specifically, the
objectives are:
1. to assess the magnitude and direction of organiza-
tional change and migration among models of PHC,
between 200 5 and 20 10, at the PHC organization
and Local Network levels as expressed by: 1) the
prevalence and local configuration of PHC organiza-
tional models; 2) conformity of PHC organizations
to a normatively defined ideal-type of organizational
characteristics; and 3) the degree of collaboration
between PHC organizations within and outside the
Local Network;
2. to determine the association of these organiza-
tional changes of PHC with factors related to the
implementation of Local Networks and policies aim-
ing at promoting new forms of PHC organization, as
well as factors related to the receptivity of PHC
organizations and the influence of professional
3. to examine the association between these organi-
zati onal changes and var ious indicators of PHC per-
formance (coverage, process and outcomes of care),
both at the organizations cliente le and the Local
Networks population levels.
Overall study design
This study employs a mix of cross-sectional a nd retro-
spective longitudinal design methods. It is also hierarch-
ical in nature with nested levels of observation:
individuals being affiliated to PHC organizations, which
are located within specific Local Networks. This study
will draw from four different sources of data to address
the identified research questions. These four sources of
data consist of: 1) individual-level data from a popula-
tion survey of peoples utilisation and experience o f
PHC; 2) individual-level data from administrative data-
bases; 3) organi zational-level data from a survey of PHC
cli nics; 4) contextual-l evel i nfo rmation from a survey of
Local Centres (cf. figure 2).
Data collected during the period of PHC reform ran-
ging from 20 05 and 2010 will be use d. The organiza-
tional and population-level data from 2005 will come
from our previously conducted study of the impact of
PHC organization models on experience of care o f
populations [1,6]. New organizational and population-
level surveys will be conducted in 2010 as part of this
research project to reassess organizat ional models and
configurations as well as population-level coverage, pro-
cesses and outcomes five years into the reform. Retro-
spective administrative data c overing the reform period
and a survey of Local Networks will complement these
data sources. Additional f ile 2 summarizes the research
themes, data sources, measurement tools and methods.
Sources of data
An organizat ion survey questionnaire will be mailed to
all 665 PHC organizations in the selected regions, in
2010. We will use a previously developed survey of orga-
nizations (Additional file 3) focusing on their vision,
material, financial and human resources, current organi-
zational structures, and organizational practices support-
ing service delivery as well as inter-organizational
collaboration [8]. Strong input from the research and
decision-maker team members will help promote a high
response rate from PHC organizations. A total of 473
organizations participated in the study conducted in
2005, for a response rate of 71% (66% in Montréal and
81% in Montérégie) [1]. The various types of private and
public PHC organizations were well represented ( solo,
group, CLSC, family medicine units, and FMG) in that
We will conduct, in 2010, a contextual appraisal of
Local Networks (n = 23) using a survey tool developed
Levesque et al. BMC Family Practice 2010, 11:95
Page 6 of 13
Page 6
in collaboration with another currently funded research
team [62]. This tool will a ssess the Local Networks
characteristics with regards to interventions aiming at
promoting organizational change and inter-organiza-
tional collaboration at the PHC level. Key informants
select ed on a pur poseful basis in each Local Centre will
include a managem ent level decision-maker, and a loc al
representative of medical associations. This survey will
be complemented with information coming from the
organization survey pertaining to the clinics perceptions
about various aspects of their organizational context and
the roles played by Local Centres in the reconfig uration
of PHC (questions in Other Application Materials sec-
tion) (see Additional file 4).
Concurrently with these two surveys, we will conduct
a t elephone population sur vey of rand omly-selected
community-dwelling individuals aged 18 and over in the
23 Local Networks of Montré al and Montérégie regions
(400 respondents in each Local Network; total sample of
9200 r espondents) using the random-di git dialling
method. Th is survey of a represen tative sa mple of th e
population will enable us to measure peoples affiliations
with PHC organizations, u tilization of healthcare ser-
vices and unmet needs for care, selected attributes of
peoples experiences of care (accessibility, continuity,
responsiveness, comprehensiveness), as well as perceived
outcomes of care. We will use a previ ously devel oped
questionnaire (Additional file 5) including validated
indices of experience of care [7]. Bas ed on our previous
work, w e can expect good rates of participation in the
survey, with response rates of 63% in Montréal and 66%
in Montérégie (Pineault et al., 2004; Pineault et al.,
2009). In order to link persons with their associated
organizational model of care, we will ask participants in
care using a previously developed algorithm based on
validated lists of PHC organizations in the two surveyed
regions (this methodology has been validated in our pre-
vious survey).
To complement the information available t hrough
population surveys, we will use administra tive databases
comprising information regarding medical services
(RAMQ), ho spital-based services (Med-Echo), pharma-
ceutical prescriptions (Pharmacare), admission in long-
term care facilities and death registry. The information
gathered will cover the full population of the two
regions and the complete span on time ranging from
2005 to 2010. The list of indicators is provided in Addi-
tional file 1.
Analytic theme 1: Assessing the magnitude of
organizational change and collaboration (Objective 1)
The definition of organization used in this study refers
to organizational entities that include one or several
general practitioners offering general medical services.
Therefore, private single-doctor offices are regarded as
organizations. Offices and c linics with more than one
physician are also considered organizations whether or
not physicians share a minimum number of resources
(rooms, secretarial services or archives), and regardless
of their degree of integration.
To assess the magnitude and direction of organiza-
tional change between 2005 and 201 0 at the PHC o rga-
nization and Local Network levels, we will use the
organizational measurement tool developed as part of a
databases indicators
T1 T2
Objective 1
Local Centres
Objective 2
Objective 3
Primary healthcare reform
databases indicators
T1 T2
Objective 1
Local Centres
Objective 2
Objective 3
Primary healthcare reform
Figure 2 Study design.
Levesque et al. BMC Family Practice 2010, 11:95
Page 7 of 13
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previously funded project [8]. Using a hierarchical classi-
fication program applied in the previous project, we will
construct an organizational taxonomy based on 2010
data and we will allocate all the organizations into mod-
els of this taxonomy through the classification compo-
nent of this pro gram [27,28]. This will provide us with a
sensitive measure of organizational change. We will
then assess in 2005 and 2010: 1) the prevalence and
local configuration of PHC o rganizational models;
2) conformity of PHC organizations to a normatively
defined ideal-type o f o rganizational characteristics; and
3) the degree of collaboration between PHC organiza-
tions within and outside the Local Network.
The distribution of organizations on all variables of
change will be compared in 2005 and 2010, globally for
the two regions, and for each Local Network territory.
To assess the migration of organizations from a model
of organization to another between 2005 and 2010, two-
level regression model s with organizations nested within
territories will be constructed, adjusting for 2005 results.
The dependent variabl e corresponding to the taxonomy
of the organizations will be dichotomous or multino-
mial, depending on the focus of analysis (single models
vs multiple models comparisons). In addition, regression
models will be developed to predict the change in con-
formity score and level of collaboration (continuous
Two-level linear models (nj = 23; nk = 450) will be built
for both categorical and continuous dependent variables.
The hierarchical models wi ll be devel oped by the pre-
determined introduction of blocks of variables related to
the three levels of analysis. Empty models will be devel-
oped to assess the level of variance comprised a t each
level of analysis. Intra-class correlations and proportion
of variance ex plained at each steps of model building
will be calculated to guide the selection of the most
appropriate models. The modelling strategy will include
fixed as well as random effect models. Bootstrapping
methods could be employed to develop robust estimates
of effect. Appropriate statistical packages will be
employed to conduct descriptive and multilevel analyses
Analytic theme 2: Identifying organizational and contextual
factors associated with organizational change (Objective 2)
To determine the influence of factors associated with
the implementation of Local Centres and new PHC
forms, as well as receptivity of PHC organizations and
the influence of professional associations, on the
changes assessed in Analytic theme 1, we will draw on
information from the organization questionnaire, as well
as from the questionnaire addressed to Local Centres
key informants.
Local Network level information and organizational
level covaria tes will be added to the two-level regressio n
models described in Analytic theme 1, using t hese vari-
ables as predictors for change in PHC organization at
the local level and in inter-organizational collaboration.
As in Analytic theme 1, our analysis will comprise all
PHC organizations (approximately 450) and all Local
Networks of the two regions (23) in 2010, paired with
organizations and Local Networks in 2005. Current
knowledge about hierarchical modelling suggests that
these sample sizes will provide sufficient statistical
power to assess the association of factors with organiza-
tional changes [63-65]. The same model building strat-
egy as in Analytic theme 1 will be employed.
Analytic theme 3: Assessing the impact of organizational
change on the performance of PHC models (Objective 3)
To address objective 3, aiming at examining the associa-
tion between these organizational changes and various
indicators of PHC performance, we will use data from
the organizational and population components of this
study. From the population questionnaire, we will calcu-
late indicators of affiliation with a primary care provider,
indicators of utilisation of healthcare services and
indices of PHC experience, as validated in our previous
study. Using the administrative databases of the entire
studied population, we will calculate indicators of utili-
sation and outcomes of care, such as hospitalisation for
ambulatory-care sensitive conditions (see Additional file
1 for details on the indicators). These various i ndicators
from the population survey and administrative databases
will be used to contrast the level of performance of dif-
ferent models of PHC organizations in 2005 and 2010
as well as comparing performance at the Lo cal Network
level during this period. Hierarchical models will be
constructed to identify the organizational factors asso-
ciated with better results regarding these indices of per -
formance of PHC at the two different times of the
study, controlling for age, gender, economic status and
morbidity, an d for the nesting of individual observations
in organizational settings and of organizations in Local
Networks settings (three-level models). These mo dels
will include a time indicator (2005 vs 2010) as well as
same- and cross-level interactions to test magnitude and
correlates of change in performance of PHC. Particular
attention will be given to the rela tionship between these
indicators and sociodemographic and socioeconomic
characteristics such as g ender and vulnerability. The
sample size will include more than 18,000 persons cor-
responding to the pooling of the two independent sam-
ples of population surveys in 20 05 and 2010. The same
model building s trategy as in Analytic t heme 1 will be
Power calculation
Power calculation always poses challenges in mul tilevel
modelling. While it is well known that multilevel
Levesque et al. BMC Family Practice 2010, 11:95
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Page 8
modelling is one of the most efficient st atistical analysis
when data structur e involves n esting of data between
levels, precise power calculation methods remain under
development. However, some general rules guiding deci-
sions regarding sampling and analyses in nested design
exist. In this study, three levels of nesting are present.
Power is influenced by the smallest sample size in the
hierarchical structure. In this study, some analyses will
use the 23 local hea lth networks. However, most ana-
lyses will analyse the data taking the organisational level
as the smallest sampling size. This level will include
more than 300 observations with a n average of 11,6
respondents per organisations. Despite variations in the
number of respondents inside each organisations, this
sample is equivalent to t he suggested s tandards in the
literature [63-65].
In addition, our design enables us to provide a power
calculation based on our most demanding analysis,
which is the multilevel analysis of theme 3, where
patients are nested in Local Networks. To calculate the
statistical power, we adopted the method of Snijders
and Bosker [64], who proposed to divide the size of the
sample by the design effect to obta in the size of the
effective sample. Analyses can then be conducted as
T-test differe nces for two independent samples with the
size of the effective sample. Since i n 2005 around 900
subjects were in the least frequent category of organiza-
tional model and the design effect was 1. 48 (1.34 and
1.66 in each of the regions), the effective sample would
be between 450 and 900 subjects for the least used orga-
nizational model. This allows us to detect a d ifference
between 0.13 and 0.19 unit o f standard deviation, with
an a of 0.05 and a power of 80%. According to Cohe n
[66], this difference can be considered as a weak effect.
As our calculati on is based on comparisons involving
the smallest numbers of subjects, our method of calcula-
tion remains conservative.
Study limits and strengths
As with any study using respondents perceptions
(population survey, organizational survey), this study
could suffer from perception bias and desirability bias,
individuals being reluctant to be critical of their PHC
clinic services and organizational respondents giving a
biased portrait of their organization s characteristics.
However, this bias should affect each type of organiza-
tion in a similar way and be conservative. In addition,
we will benefit from information coming from adminis-
trative databases and will be able to compare p erceptual
information with harder data c ollected through these
Another limitation is that the information will come
from a single province and wi ll assess specific aspects of
performance of PHC organizations. Other aspects such
as economic pr oductivity, technicalqualityofcareor
impact on health outcomes are not easily measured by
population and organizational surveys. However, this
survey will provide the first in-depth analysis of a PHC
system, providing population coverage. In addition, our
knowledge translation plan includes a national advisors
meeting to discuss the applicability of our result s to
other Canadian contexts.
This study also benefits from specifi c strengths. Firs t,
the u se of both taxonomic approaches and single char-
acteristics assessments will en able the researche rs to
asse ss the impact of organizations in light of their com-
plexity as well as identifying certain key characteristics
that can have a specific impact on their performance.
Furthermore, its longitudinal de sign and nominal link
between users and their PHC organizations will enable
the research tea m to assess the dire ction ality of associa-
tions being measured, something missing from many
cross-sectional surveys of PHC organizations perfor-
mance. Finally, the explicit con ceptual framework used
in this study will enable the research team to test appro-
priate hypotheses with a clear explanator y framework to
guide the co-creation of knowledge between decision-
makers and researchers.
Knowledge translation and exchange plan
Our knowledge translation and exchange (KTE) strategy
is based on the conceptual formulation presented by
Klein [67], who distinguishes three types of evidence:
scientific, organization and political. Scientific evidence
is produced by researchers. Organizational evidence
concerns the feasibility of solutions emerging from
scientific research. Finally, political evidence looks at the
desirability of these solutions. Each type of evidence
addresses different target audiences for KTE activities:
the research community; the decision/policy m akers,
including politicians and pressure groups; and the ge n-
eral public. In addition to p resentation during scientific
meetings targeting exchange in know ledge among the
scientific community, our KTE activities will target four
specific audiences.
The first audience is the regional and Local Network
levels, particularly the two regional health agencies, that
participate in the coproduction and the financing of this
research. The experience acquired in the preceding pro-
ject and the links we have es tablished with the decision-
makers of the two agencies will facilitate our task in
KTE activities. First, one of the decision-makers
(D. Roy) is principal co-investigator of the project.
Timeliness is an important condition for the use o f
research results by d ecision-makers [68]. C onsequently,
we will respond to i nvitations from the two agencies to
present our preliminary findings, as soon as they
become available. Our experience in the preceding
Levesque et al. BMC Family Practice 2010, 11:95
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project has taught us that decision-makers are mainly
interested by descriptive data of the experience of care
of their population and of their PHC organizations. We
intend to repeat that strategy that will extend to Local
Centres, as we will provide them with a picture of their
A s econd audience is PHC clinicians. As in the pre-
ceding project, we will seize any opportunity to partici-
pate in the regional meeting of the Regional Department
of Medicine of the two regions a nd to meet with the
local medical associations. This proved to be very fruit-
ful in the past, as we have established solid links with
the medical leaders. In addition, at the end of the pro-
ject, a feedback report will be sen t to each participati ng
clinic, showing the performance of the models of the
taxonomy and to which model they belong. This feed-
back was greatly appreciated in the previous project and
prepared the ground for future participation.
A third audience is the Ministry of Health and Social
Services, that has expressed great interest in and support
for our project. In May 2009, we are invited (JFL and RP)
with Bill Ho gg, to attend a one-day consultation meeting
on the organization of PHC in Québec. We will meet on a
regular basis with the persons responsible for the imple-
mentation of FMGs and evaluation of services, to keep
them informed of our findings, as soon as they are
A fourth audience is the general public. We can count
on the support of our two institutions, the Institut national
de santé publique du Québec and the Direction de santé
publique (Public Health Department) de lAgen ce de la
santé et des services sociaux de Montréal, that have a
great deal of expertise and experience in publicizing
research to the general population. In addition, we have
established strong links with the media in previous pro-
jects that will benefit this aspect of our KTE plan.
We expect that our KTE plan, by targeting these dif-
ferent audiences, will ha ve a major impact. Knowledge
translation activities will revolve around the collabora-
tion with established groups (GETOS, GRGT, INSPQ)
and use their established links and networks of knowl-
edge exc hange. Presentations to the various collaborat-
ing agencies will occur and scientific publications will be
accompanied with policy-oriented timely documents.
These documents will include descriptive reports related
to the experience of care a nd organization of PHC at
the local and regional l evels, methodological reports
related to the various components of the study and the-
matic r eports focusing on policy-relevant subjects (e.g.
unmet needs, PHC affiliation , access for vulner able
populations). The expertise of many of our team mem-
bers on this front will ensu re effective knowledge tra ns-
lation and exchange. Examples of reports recently
produced by the research team are available in Other
Application Materials section.
Finally, jus t before we produce the final report of this
research, we will organize a national me eting on PHC,
where we will share with researchers, decision/policy
makers, and representatives of the public, the result s of
our resea rch, alon g with those of other resea rch teams,
namely the Ottawa team, with which we have estab-
lished collaborations. In preparation for this event, we
will prepare a synthesis of findings produced by
researchers in Ontario, Québec, and bC. This will be
done following the methodology that we adopted in
conducti ng a research col lective and specifi cally in inte-
grating the decision-makers viewpoints in producing a
synthesis [69-71].
Additional material
Additional file 1: List of indicators and measures. This file lists
indicators used for each of the three research themes along with their
measures and sources.
Additional file 2: Research program grid. This file specifies for each
research theme the source of data, the measurement tools and the
analytic procedures to be used.
Additional file 3: Organizational Questionnaire. The organizational
questionnaire contains all the questions completed by each PHC
organization. It pertains to various aspects of these organizations such as
vision, structure, resources and practices. The last section deals with the
reorganization of PHC services.
Additional file 4: CSSS Questionnaire. This file contains the
questionnaire completed by key informants of Local Centres. It explores
mainly the role played by Local Centres in developing interorganizational
collaboration and networking as well as the support they gave to
emerging forms of PHC organizations.
Additional file 5: Population Questionnaire. This file contains the
questionnaire used in the population survey. Questions relate mainly to
experience of care, utilization and unmet needs.
We aknowledge the contribution of the following collaborators and
researchers associated with the project : D. Roy, J.L. Denis, P. Lamarche, M.D.
Beaulieu, D. Feldman, J. Haggerty, D. Roberge, J. Côté, M. Fournier, M. Hamel,
F. Goulet, M. Drouin, J. Rodrigue, L. Côté, and Odette Lemoine.
The study benefits from the financial contributions of the Canadian Institutes
of Health Research, the Fonds de recherche en santé du Québec, the
Agence de la santé et des services sociaux de Montréal and the Agence de
la santé et des services sociaux de la Montérégie.
Author details
Institut national de santé publique du Québec, Québec, Canada.
Centre de
recherche du Centre hospitalier de lUniversité de Montréal, Québec, Canada.
Direction de santé publique de lAgence de la santé et des services sociaux
de Montréal, Québec, Canada.
Authors contributions
Understanding the evolution of PHC organizational models and their relative
performance through the reform of PHC and assess the factors, at the
organizational and contextual levels, associated with the transformation of
PHC organizations and their performance, requires a diversity of skills and
Levesque et al. BMC Family Practice 2010, 11:95
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Page 10
JFL, designated PI, will lead the project and be involved in all steps of the
study, including knowledge translation and exchange (KTE). His experience
as co-PI on project Accessibility and Continuity of Care: A Study of PHC in
Québec (CHSRF-funded) will ensure continuity between T1 and T2 of the
research. Through his experience in policy making and research in PHC, he
has acquired unique expertise and skills to coordinate a research team of
researchers and decision-makers. He read and approved the final manuscript.
DAR, as Principal Decision-maker, will take part in the overall conduct of the
study and strategic planning of research and KTE activities with the principal
investigators. RP, co-PI, has led project Accessibility and Continuity of Care: A
Study of PHC in Québec with Dr Levesque and will serve as senior
investigator and mentor for the team. He will bring an important
contribution to all components of the research, including KTE. He read and
approved the final manuscript. PT is co-PI. As senior researcher and expert in
disease surveillance, administrative database studies and population-based
surveys, he will lead the databases indicator development component of
this project (Theme 3). He read and approved the final manuscript.
The co-investigators will be involved more specifically in different
components (Analytic themes) of the project. JLD holds a Research Chair
from CIHR and CHSRF (cadre program) aiming at improving knowledge base
and KTE with regards to the analysis of organizational change. He will
contribute more specifically to Theme 2. PL has extensive experience in the
analysis of healthcare policy and systems. His experience will be useful for
the conduct of the organizational component of this research (Theme 1). SP
has expertise in public-health surveillance, clinical preventive practices and
surveys. She will be involved in the different components of this project and
more specifically in Theme 3. She read and approved the final manuscript.
MDB is the current holder of the Chaire Sadok-Besrour in Family Medicine.
The expertise she brings to the team includes in-depth understanding of
PHC organization and experience of care (Themes 1 and 3). DF will
contribute to Theme 3 with her experience in outcome measurement,
access to services, and use of administrative databases for health research.
JH holds a Canada Research Chair on the population impact of primary
healthcare organizations. Her extensive knowledge in measurement of
patients experiences with PHC will be contributive in Theme 3. DR was
involved in the project Accessibility and Continuity of Care: A Study of PHC
in Québec as co-PI with Dr Levesque and Pineault. Her extensive knowledge
and research experience in qualitative research will be a great asset in
Theme 2. JC has acquired a vast experience in integrated care for specific
populations and will bring the viewpoint of nursing in the provision of PHC
(Theme 1). MF is statistician. His expertise will be required in quantitative
analysis throughout the project. MH was co-investigator and coordinator of
the project Accessibility and Continuity of Care: A Study of PHC in Québec.
She will ensure the link between T1 and T2 of the research, more specifically
in Theme 1. AC will bring her assistance in the overall coordination of the
project and will be involved more specifically in Theme 1. She read and
approved the final manuscript. RBDS and MB are postdoctoral trainees who
will be involved in organizational and contextual analyses respectively. They
read and approved the final manuscript.
Co-decision-makers on the project will bring substantive support in KTE
activities in their specific professional sphere: FG in the medical community;
MD in public health; and JR in the linkage between physicians and decision-
makers. LC is active in the implementation of new forms of PHC in Montréal
region. His strategic position will facilitate KTE activities among top level
Finally, in order to achieve a bi-directional flow of information between
investigators and decision-makers, we will establish an advisory committee
composed of collaborators coming from clinical, management and policy
fields. Regional and provincial bodies will also be part of this advisory group.
This advisory committee will also benefit from the participation of
recognized researchers in PHC from other Canadian provinces as well as
national associations in order to broaden the scope of the study and ensure
a larger transferability of the results. An innovative feature of our research
program is the longitudinal nature of the program of research. We plan to
complement the aforementioned areas of studies with inquiries suggested
by the advisory committee throughout the program of research. This will
enable the advisory committee to influence the ongoing processes of data
collection and analyses. In return, this body will provide organizational
insights into the findings.
Competing interests
The authors declare that they have no competing interests.
Received: 22 July 2010 Accepted: 1 December 2010
Published: 1 December 2010
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Cite this article as: Levesque et al.: Assessing the evolution of primary
healthcare organizations and their performance (2005-2010) in two
regions of Québec province: Montréal and Montérégie. BMC Family
Practice 2010 11:95.
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Levesque et al. BMC Family Practice 2010, 11:95
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    • "It focused on respondents' attachment to a PHC practice, experience of care, and use of services in the two years preceding the surveys as well as unmet needs in the six months preceding the survey. The population questionnaire documented also individual characteristics such as gender, age, level of education, economic status, perceived health, and presence of morbidities [25]. Population surveys data were linked with information gathered on PHC organization through respondents' identification of their regular source of primary care in the two years preceding the survey (2003–2005 and 2008–2010). "
    [Show abstract] [Hide abstract] ABSTRACT: Objectives . To assess the extent to which new primary healthcare (PHC) models implemented in two regions of Quebec have improved patient experience of care, unmet needs, and use of services for individuals with and without chronic diseases, compared with other forms of PHC practices. Methods . In 2005 and 2010, we carried out population and organization surveys. We divided PHC organizations into new model practices and other practices and followed the evolution over time of patient experience of care. Results . Patients with chronic diseases had better accessibility but worse continuity of care in the new model practices than in the other practices at both time periods. Through the reform, accessibility decreased evenly in both groups, but continuity and perceived outcomes improved more in the other practices. Use of primary care services decreased more in the new model practices. Among patients without chronic disease, accessibility decreased much less in the new models and responsiveness increased more. There was no significant change in ER attendance and hospitalization. Conclusion . The evolution of patient experience of care has been more favorable for patients without chronic diseases. These findings raise concerns about equity since the aim of the PHC reform was targeting in priority individuals with the greatest needs.
    Full-text · Article · Apr 2016
    • "That study found an increase in continuity but a decrease in accessibility after 18 months among the patients enrolled in those FMGs. Our study is not comparable to the Tourigny et al. study in many regards, namely, number of FMGs studied, inclusion of NCs as new forms of PHC organizations, and regions covered by the study [23, 38]. Our population sample size and the large number of PHC organizations surveyed allow us to generalize with a fair degree of confidence, at least for the two regions under study. "
    [Show abstract] [Hide abstract] ABSTRACT: . Healthcare reforms launched in the early 2000s in Québec, Canada, involved the implementation of new forms of primary healthcare (PHC) organizations: Family Medicine Groups (FMGs) and Network Clinics (NCs). The objective of this paper is to assess how the organizational changes associated with these reforms have impact on patients’ experience of care, use of services, and unmet needs. Methods . We conducted population and organization surveys in 2005 and 2010 in two regions of the province of Québec. The design was a before-and-after natural experiment. Changes over time between new models and other practices were assessed using difference-in-differences statistical procedures. Results . Accessibility decreased between 2003 and 2010, but less so in the treatment than in the comparison group. Continuity of care generally improved, but the increase was less for patients in the treatment group. Responsiveness also increased during the period and more so in the treatment group. There was no other significant difference between the two groups. Conclusion . PHC reform in Québec has brought about major organizational changes that have translated into slight improvements in accessibility of care and responsiveness. However, the reform does not seem to have had an impact on continuity, comprehensiveness, perceived care outcomes, use of services, and unmet needs.
    Full-text · Article · Feb 2016
    • "The final analysis of barriers and facilitators was performed using a framework adapted from institutional theory, which views organizational change as resulting from three types of environmental influences, namely, coercive (laws, regulations, policies), normative (professional influences and culture) and mimetic (presence of champions and successful leaders) influences, as well as receptivity to change within the practices (perceptions and attitudes) (dimaggio and Powell 1991; meyer and Rowan 1991; scott et al. 2000). We adapted the framework for this study (Levesque et al. 2010 ). This framework proved to be useful in providing a classification system to critically appraise the factors that have been identified to be crucial in facilitating or impeding primary healthcare reforms in the studied provinces. "
    [Show abstract] [Hide abstract] ABSTRACT: Introduction: Since 2000, primary care (PC) reforms have been implemented in various Canadian provinces. Emerging organizational models and policies are at various levels of implementation across jurisdictions. Few cross-provincial analyses of these reforms have been realized. The aim of this study is to identify the factors that have facilitated or hindered implementation of reforms in Canadian provinces between 2000 and 2010. Methods: A literature and policy scan identified evaluation studies across Canadian jurisdictions. Experts from British Columbia, Manitoba, Nova Scotia, Ontario and Quebec were asked to review the scope of published evaluations and draft provincial case descriptions. A one-day deliberative forum was held, bringing together researchers (n = 40) and decision-makers (n = 20) from all the participating provinces. Results: Despite a relative lack of published evaluations, our results suggest that PC reform has varied with regard to the scope and the policy levers used to implement change. Some provinces implemented specific PC models, while other provinces designed overarching policies aiming at changing professional behaviour and practice. The main perceived barriers to reform were the lack of financial investment, resistance from professional associations, too overtly prescriptive approaches lacking adaptability and an overly centralized governance model. The main perceived facilitators were a strong financial commitment using various allocation and payment approaches, the cooperation of professional associations and an incremental emergent change philosophy based on a strong decentralization of decisions allowing adaptation to local circumstances. So far the most beneficial results of the reforms seem to be an increase in patients' affiliation with a usual source of care, improved experience of care by patients and a higher workforce satisfaction. Conclusion: PC reforms currently under consideration in other jurisdictions could learn from the factors identified as promoting or hindering change in the provinces that have been most proactive.
    Full-text · Article · Jan 2016
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