BackgroundThe new forms of organization of healthcare services entail the development of new clinical practices that are grounded in collaboration. Despite recent advances in research on the subject of collaboration, there is still a need for a better understanding of collaborative processes and for conceptual tools to help healthcare professionals develop collaboration amongst themselves in complex systems. This study draws on D'Amour's structuration model of collaboration to analyze healthcare facilities offering perinatal services in four health regions in the province of Quebec. The objectives are to: 1) validate the indicators of the structuration model of collaboration; 2) evaluate interprofessional and interorganizational collaboration in four health regions; and 3) propose a typology of collaborationMethodsA multiple-case research strategy was used. The cases were the healthcare facilities that offer perinatal services in four health regions in the province of Quebec (Canada). The data were collected through 33 semi-structured interviews with healthcare managers and professionals working in the four regions. Written material was also analyzed. The data were subjected to a "mixed" inductive-deductive analysis conducted in two main stages: an internal analysis of each case followed by a cross-sectional analysis of all the cases.ResultsThe collaboration indicators were shown to be valid, although some changes were made to three of them. Analysis of the data showed great variation in the level of collaboration between the cases and on each dimension. The results suggest a three-level typology of collaboration based on the ten indicators: active collaboration, developing collaboration and potential collaboration.ConclusionThe model and the typology make it possible to analyze collaboration and identify areas for improvement. Researchers can use the indicators to determine the intensity of collaboration and link it to clinical outcomes. Professionals and administrators can use the model to perform a diagnostic of collaboration and implement interventions to intensify it.

PURPOSE In 2004, we undertook a consultation with Canadian primary health care experts to defi ne the attributes that should be evaluated in predominant and proposed models of primary health care in the Canadian context. METHOD Twenty persons considered to be experts in primary health care or recommended by at least 2 peers responded to an electronic Delphi process. The expert group was balanced between clinicians (principally family physicians and nurses), academics, and decision makers from all regions in Canada. In 4 iterative rounds, participants were asked to propose and modify operational defi nitions. Each round incorporated the feedback from the previous round until consensus was achieved on most attributes, with a fi nal consensus process in a face-to-face meeting with some of the experts. RESULTSOperational defi nitions were developed and are proposed for 25 attributes; only 5 rate as specifi c to primary care. Consensus on some was achieved early (relational continuity, coordination-continuity, family-centeredness, advocacy, cultural sensitivity, clinical information management, and quality improvement process). The defi nitions of other attributes were refi ned over time to increase their precision and reduce overlap between concepts (accessibility, quality of care, interpersonal communication, community orientation, comprehensiveness, multidisciplinary team, responsiveness, integration).CONCLUSION This description of primary care attributes in measurable terms provides an evaluation lexicon to assess initiatives to renew primary health care and serves as a guide for instrument selection. Med;5:336-344. DOI: 10.1370/afm.682. Ann Fam INTRODUCTIONH ealth systems based on a strong primary health care system are more effective and effi cient than those centered on specialty and tertiary care.1 In Canada, various national and provincial commissions on health care [2][3][4][5][6][7][8] concluded that strengthening and expanding primary health care will meet Canadians' needs for prompt access to comprehensive evidence-based services. Major initiatives have also been undertaken in New Zealand and the United Kingdom to strengthen primary health care. 9,10 As health systems worldwide engage in evaluation efforts to assess the impacts of primary health care renewal initiatives, there is a critical need to provide evaluation frameworks and tools to facilitate these efforts.An important starting point for evaluation is an operational defi nition of the dimension being evaluated. An operational defi nition is a description of a concept in measurable terms. It is used to remove ambiguity, to serve as a guide for the selection of measurement tools, and to reduce the likelihood of disparate results between different data collections. 337 AT T R IBU T ES O F PR IM A RY HE A LT H C A R Edevelop a common lexicon of operational defi nitions of attributes to be evaluated in predominant and emerging models of primary health care in Canada, but many of these defi nitions will be relevant to primary health care mode...

Background: People aged 65 years or more represent a growing group of emergency department users. We investigated whether characteristics of primary care (accessibility and continuity) are associated with emergency department use by elderly people in both urban and rural areas. Methods:We conducted a cross-sectional study using information for a random sample of 95 173 people aged 65 years or more drawn from provincial administrative databases in Quebec for 2000 and 2001. We obtained data on the patients' age, sex, comorbidity, rate of emergency department use (number of days on which a visit was made to an amergency department per 1000 days at risk [i.e., alive and not in hospital] during the 2-year study period), use of hospital and ambulatory physician services, residence (urban v. rural), socioeconomic status, access (physician: population ratio, presence of primary physician) and continuity of primary care. Results:After adjusting for age, sex and comorbidity, we found that an increased rate of emergency department use was associated with lack of a primary physician (adjusted rate ratio [RR] 1.45, 95% confidence interval [CI] 1.41-1.49) and low or medium (v. high) levels of continuity of care with a primary physician (adjusted RR 1.46, 95% CI 1.44-1.48, and 1.27, 95% CI 1.25-1.29, respectively). Other significant predictors of increased use of emergency department services were residence in a rural area, low socioeconomic status and residence in a region with a higher physician:population ratio. Among the patients who had a primary physician, continuity of care had a stronger protective effect in urban than in rural areas.Interpretation: Having a primary physician and greater continuity of care with this physician are factors associated with decreased emergency department use by elderly people, particularly those living in urban areas. Abstract CMAJ 2007;177(11):1362-8From the

PURPOSE On the eve of major primary health care reforms, we conducted a multilevel survey of primary health care clinics to identify attributes of clinic organization and physician practice that predict accessibility, continuity, and coordination of care as experienced by patients.METHODS Primary health care clinics were selected by stratifi ed random sampling in urban, suburban, rural, and remote locations in Quebec, Canada. Up to 4 family or general physicians were selected in each clinic, and 20 patients seeing each physician used the Primary Care Assessment Tool to report on fi rst-contact accessibility (being able to obtain care promptly for sudden illness), relational continuity (having an ongoing relationship with a physician who knew their particulars), and coordination continuity (having coordination between their physician and specialists). Physicians reported on aspects of their practice, and secretaries and directors reported on organizational features of the clinic. We used hierarchical regression modeling on the subsample of regular patients at the clinic. RESULTSOne hundred clinics participated (61% response rate), for a total of 221 physicians and 2,725 regular patients (87% response and completion rate). Firstcontact accessibility was most problematic. Such accessibility was better in clinics with 10 or fewer physicians, a nurse, telephone access 24 hours a day and 7 days a week, operational agreements to facilitate care with other health care establishments, and evening walk-in services. Operational agreements and evening care also positively affected relational continuity. Physicians who valued continuity and felt attached to the community fostered better relational continuity, whereas an accessibility-oriented style (as indicated by a high proportion of walk-in care and high patient volume) hindered it. Coordination continuity was also associated with more operational agreements and continuous telephone access, and was better when physicians practiced part time in hospitals and performed a larger range of medical procedures in their offi ce. CONCLUSIONSThe way a clinic is organized allows physicians to achieve both accessibility and continuity rather than one or the other. Features that achieve both are offering care in the evenings and access to telephone advice, and having operational agreements with other health care establishments.

The scale can be used by physicians or primary health care units and has a wide range of applications.