BackgroundWith 4.6 million patients who do not have a regular family physician, Canada performs poorly compared to other OECD countries in terms of attachment to a family physician. To address this issue, several provinces have implemented centralized waiting lists to coordinate supply and demand for attachment to a family physician. Although significant resources are invested in these centralized waiting lists, no studies have measured their performance. In this article, we present a performance assessment of centralized waiting lists for unattached patients implemented in Quebec, Canada.MethodsWe based our approach on the Balanced Scorecard method. A committee of decision-makers, managers, healthcare professionals, and researchers selected five indicators for the performance assessment of centralized waiting lists, including both process and outcome indicators. We analyzed and compared clinical-administrative data from 86 centralized waiting lists (GACOs) located in 14 regions in Quebec, from April 1, 2013, to March 31, 2014.ResultsDuring the study period, although over 150,000 patients were attached to a family physician, new requests resulted in a 30% median increase in patients on waiting lists. An inverse correlation of average strength was found between the rates of patients attached to a family physician and the proportion of vulnerable patients attached to a family physician meaning that as more patients became attached to an FP through GACOs, the proportion of vulnerable patients became smaller (r = −0.31, p < 0.005). The results showed very large performance variations both among GACOs of different regions and among those of a same region for all performance indicators.ConclusionsCentralized waiting lists for unattached patients in Quebec seem to be achieving their twofold objective of attaching patients to a family physician and giving priority to vulnerable patients. However, the demand for attachment seems to exceed the supply and there appears to be a tension between giving priority to vulnerable patients and attaching of a large number of patients. Results also showed heterogeneity in the performance of centralized waiting lists across Quebec. Finally, our findings suggest it is critical that similar mechanisms should use available data to identify the best strategies for reducing variations and improving performance.Electronic supplementary materialThe online version of this article (doi:10.1186/s12875-016-0573-1) contains supplementary material, which is available to authorized users.

BackgroundInterdisciplinary teamwork (ITW) is deemed necessary for quality cancer care practices. Nevertheless, variation in ITW intensity among cancer teams is understudied, and quantitative evidence of the effect of different ITW intensities among cancer teams on patients’ perceived experience of care is limited. This study aims to compare patient-reported experience measures (PREMs) of cancer outpatients followed by teams characterized by high vs. low ITW intensity.MethodsThe study is designed as an ex post facto quasi-experimental study. Participants (n = 1379) were recruited in nine outpatient oncology clinics characterized by different ITW intensities. ITW intensities were evaluated using the characteristics of structure (team composition and size) and process (interactions among team members), as per West’s seminal work on team effectiveness. ITW intensity was dichotomized (high vs. low ITW intensity). PREMs were classified and measured using validated scales corresponding to six dimensions: Prompt access to care, Person-centred response, Quality of patient-professional communication, Quality of the care environment, Continuity of care, and Results of care. Dichotomous variables were created for each dimension (positive vs. less positive experience). Multiple logistic regression analyses were performed to assess the association between ITW intensities and the six PREMs dimensions, while controlling for patient and organizational characteristics. PROC GENMOD was used to fit logistic models for categorical variables.ResultsOutpatients treated by teams characterized by high ITW intensity reported almost four times more positive perceptions of Prompt access to care compared to patients treated by low ITW intensity teams (OR = 3.99; CI = 1.89–8.41). High ITW intensity also positively affected patients’ perceptions of Quality of patient-professional communication (OR = 2.37; CI = 1.25–4.51), Person-centred response (OR = 2.11; CI = 1.05–4.24], and Continuity of care (OR = 2.18; CI = 1.07–4.45). No significant association was found between ITW intensity and perceived Results of care (OR = 1.31; CI = 0.68–2.52) or Quality of the care environment (OR = 0.66; CI = 0.31–1.39).ConclusionsThis study provides empirical evidence, from the patient’s perspective, that ITW intensity affects some critical aspects of patient-reported quality of care. Future research will allow explaining how and why ITW structure and processes may contribute to positive cancer care experiences.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-017-2166-7) contains supplementary material, which is available to authorized users.

Objective: A 2002 survey of primary healthcare sites found that 51% of rural and 33% of urban primary care patients reported using the hospital emergency room (ER) in the last 12 months. We did a secondary analysis to identify urban-rural differences in accessibility-related organizational features that predicted ER use. Methods: We collected information on clinic organization and physicians' practice profiles from 100 primary healthcare sites across Quebec and 2,725 of their regular patients, who reported on ER use. We used hierarchical logistic regression to identify organizational features that predict the probability of ER use by patients. Results: Patient confidence in rapid access at their clinic decreases ER use (OR=0.73). Rural sites offer fewer walk-in services or on-site medical procedures and less proximity to laboratory and diagnostic services, but paradoxically, rural patients are more confident that their own physician will see them for a sudden illness. Patients from clinics offering a larger range of medical procedures on site have lower ER use (OR=0.92 per procedure). Rural physicians tend to divide their time between hospital and primary care; doing in-patient care increases ER use (OR=1.64). Discussion: Decreased ER use is found in patients of clinics organized to enhance responsiveness to acute needs, especially in rural areas. Although the high rates of ER use in rural areas partly reflect problems with the accessibility of primary care clinics, in a resource-scarce context rural hospital ERs may cover both primary care urgent problems and emergencies. Résumé Objectif : Une enquête réalisée en 2002 auprès de sites de soins de première ligne a révélé que 51 % des patients recevant des soins primaires en milieu rural et 33 % des patients recevant des soins primaires en milieu urbain ont déclaré avoir utilisé le service des urgences d'un hôpital au cours des 12 derniers mois. Nous avons effectué une analyse secondaire pour repérer les différences entre les milieux urbains et ruraux sur

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In Quebec, several primary care physicians have made the transition to the advanced access model to address the crisis of limited access to primary care. The objectives are to describe the implementation of the advanced access model, as perceived by the first family physicians; to analyze the factors influencing the implementation of its principles; and to document the physicians' perceptions of its effects on their practice, colleagues and patients. Qualitative methods were used to explore, through semi-structured interviews, the experiences of 21 family physicians who had made the transition to advanced access. Of the 21 physicians, 16 succeeded in adopting all five advanced access principles to varying degrees. Core implementation issues revolved around the dynamics of collaboration between physicians, nurses and other colleagues. Secretaries' functions, in particular, had to be expanded. Facilitating factors were mainly related to the physicians' leadership and the professional resources available in the organizations. Impediments related to resource availability and team functioning were also encountered. This is the first exploratory study to examine the factors influencing the adoption of the advanced access model conducted with early-adopter family physicians. The lessons drawn will inform discussions on scaling up to other settings experiencing the same problems. Copyright © 2016 John Wiley & Sons, Ltd.

BackgroundTeamwork is a key component of the health care renewal strategy emphasized in Quebec, elsewhere in Canada and in other countries to enhance the quality of oncology services. While this innovation would appear beneficial in theory, empirical evidences of its impact are limited. Current efforts in Quebec to encourage the development of local interdisciplinary teams in all hospitals offer a unique opportunity to assess the anticipated benefits. These teams working in hospital outpatient clinics are responsible for treatment, follow-up and patient support. The study objective is to assess the impact of interdisciplinarity on cancer patients and health professionals.Methods/DesignThis is a quasi-experimental study with three comparison groups distinguished by intensity of interdisciplinarity: strong, moderate and weak. The study will use a random sample of 12 local teams in Quebec, stratified by intensity of interdisciplinarity. The instrument to measure the intensity of the interdisciplinarity, developed in collaboration with experts, encompasses five dimensions referring to aspects of team structure and process. Self-administered questionnaires will be used to measure the impact of interdisciplinarity on patients (health care utilization, continuity of care and cancer services responsiveness) and on professionals (professional well-being, assessment of teamwork and perception of teamwork climate). Approximately 100 health professionals working on the selected teams and 2000 patients will be recruited. Statistical analyses will include descriptive statistics and comparative analysis of the impact observed according to the strata of interdisciplinarity. Fixed and random multivariate statistical models (multilevel analyses) will also be used.DiscussionThis study will pinpoint to what extent interdisciplinarity is linked to quality of care and meets the complex and varied needs of cancer patients. It will ascertain to what extent interdisciplinary teamwork facilitated the work of professionals. Such findings are important given the growing prevalence of cancer and the importance of attracting and retaining health professionals to work with cancer patients.

Based on lessons learned from the evaluation of the implementation of an integrated oncological services network in Québec, this paper discusses the following question: to what extent is strong clinical leadership a propitious means of transforming health-care systems, especially when the change leads to significant evolution in inter-professional and inter-organizational relations? Through a qualitative case study, we analysed the exercising of leadership by studying over time the clinical leaders' initiatives while trying to understand the sources of influence, the nature of the tactics adopted and their consequences for the degree of integration of health services. This study seems to show that clinical leadership is effective but limited. We conclude that a constellation of clinical, administrative and political leaders found at different levels of the health-care system offers more promise of positive change for the health-care system.

BackgroundAccess to primary healthcare is an important social determinant of health and having a regular general practitioner (GP) has been shown to improve access. In Canada, socio-economically disadvantaged patients are more likely to be unattached (i.e. not have a regular GP). In the province of Quebec, where over 30% of the population is unattached, centralized waiting lists were implemented to help patients find a GP. Our objectives were to examine the association between social and material deprivation and 1) likelihood of attachment, and 2) wait time for attachment to a GP through centralized waiting lists.MethodsA cross-sectional study was conducted in five local health networks in Quebec, Canada, using clinical administrative data of patients attached to a GP between June 2013 and May 2015 (n = 24, 958 patients) and patients remaining on the waiting list as of May 2015 (n = 49, 901), using clinical administrative data. Social and material area deprivation indexes were used as proxies for patients’ socio-economic status. Multiple regressions were carried out to assess the association between deprivation indexes and 1) likelihood of attachment to a GP and 2) wait time for attachment. Analyses controlled for sex, age, local health network and variables related to health needs.ResultsPatients from materially medium, disadvantaged and very disadvantaged areas were underrepresented on the centralized waiting lists, while patients from socially disadvantaged and very disadvantaged areas were overrepresented. Patients from very materially advantaged and advantaged areas were less likely to be attached to a GP than patients from very disadvantaged areas. With the exception of patients from socially disadvantaged areas, all other categories of social deprivation were more likely to be attached to a GP compared to patients from very disadvantaged areas. We found a pro-rich gradient in wait time for attachment to a GP, with patients from more materially advantaged areas waiting less than those from disadvantaged areas.ConclusionOur findings suggest that there are socio-economic inequities in attachment to a GP through centralized waiting lists. Policy makers should take these findings into consideration to adjust centralized waiting list processes to avoid further exacerbation of health inequities.