The Ecology of Sustainable Implementation

Birdsell

et al. 2020

Preprint

Background: Primary care, and its transformation into Primary Health Care (PHC), hasbecome an area of intense policy interest around the world. As part of this trendAlberta, Canada, has implemented Primary Care Networks (PCNs). These aredecentralized organizations, mandated with supporting the delivery of PHC, fundedthrough capitation, and operating as partnerships between the province’s healthcareadministration system and family physicians. This paper provides an implementationhistory of the PCNs, giving a detailed account of how people, time, and culturehave interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment.Methods: Our implementation history is built out of an analysis of policy documentsand qualitative interviews. We conducted an interpretive analysis of relevant policydocuments (n=20) published since the first PCN was established. We then grounded12 semi-structured interviews in that initial policy analysis. These interviews explored11 key stakeholders’ perceptions of PHC transformation in Alberta generally, and theformation and evolution of the PCNs specifically. The data from the policy review andthe interviews were coded inductively, with participants checking our emerginganalyses.Results: Over time, the PCNs have shifted from an initial Frontier Era thatemphasized local solutions to local problems and featured few rules, to a present Eraof Accountability that features central demands for standardized measures,governance, and co-planning with other elements of the health system. A core groupof people – clinician and administration leaders – emerged to create the PCNs and,over time , to develop a long-term Quality Improvement (QI) vision and governanceplan for them as organizations. The continuing willingness of both these groups towork at understanding and aligning one another’s cultures to achieve thetransformation towards PHC has been central to the PCNs’ survival and success.Conclusions: Generalizable lessons from the implementation history of this emergingpolicy experiment include: The need for flexibility within a broad commitment toimproving quality. The importance of time for individuals and organizations to learnabout: quality improvement; one another’s cultures; and how best to support thetransformation of a system while delivering care locally.

Section: Methodsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

An Implementation History of Primary Health Care Transformation: Alberta’s Primary Care Networks and the People, Time and Culture of change

Birdsell

et al. 2020

Preprint

“…We conducted an interpretive qualitative study to better understand the PCNs' implementation history, and so generate a rich, contextualized account of these particular PHC transformation efforts. We approach the ecology of the PCNs as being a recursive interaction between policy documents, human experiences, and institutional history (26). In taking this approach we developed a recursive two phase method aimed at highlighting the factors -what would become in our ndings the people, time, and culture -which have interacted to see the PCNs not just survive, but incrementally evolve from the bottom up in a FFS environment.…”

Section: Methodsmentioning

confidence: 99%

“…It takes place in Alberta, one of Canada's 14 health jurisdictions (1 federal, 10 provincial and 3 territorial ministries of health), each of which is responsible for the governance, organization, and delivery of health services to speci c populations. We present an implementation history (26) describing the ecology and evolution of particular transformation efforts undertaken not in an integrated, centrally managed primary care system, but rather in a single payer, fee-for-service (FFS) environment. In this sense Alberta becomes a case study that focuses on understanding the productive possibilities that exist in the space between PHC aims as written and changes in practice on the ground.…”

Section: Introductionmentioning

confidence: 99%

An Implementation History of Primary Health Care Transformation: Alberta’s Primary Care Networks and the People, Time and Culture of change

Birdsell

et al. 2020

Preprint

Background: Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province’s healthcare administration system and family physicians. This paper provides an implementationhistory of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment.Methods: Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n=20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders’ perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses.Results: Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another’s cultures to achieve the transformation towards PHC has been central to the PCNs’ survival and success.Conclusions: Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another’s cultures; and how best to support the transformation of a system while delivering care locally.

“…It takes place in Alberta, one of Canada’s 14 health jurisdictions (1 federal, 10 provincial and 3 territorial ministries of health), each of which is responsible for the governance, organization, and delivery of health services to specific populations. We present an implementation history [ 25 ] describing the ecology and evolution of particular transformation efforts undertaken not in an integrated, centrally managed primary care system, but rather in a single payer, fee-for-service (FFS) environment. In this sense Alberta becomes a case study that focuses on understanding the productive possibilities that exist in the space between PHC aims as written and changes in practice on the ground.…”

Section: Introductionmentioning

confidence: 99%

An implementation history of primary health care transformation: Alberta’s primary care networks and the people, time and culture of change

Birdsell³

et al. 2020

BMC Fam Pract

Background Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province’s healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment. Methods Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders’ perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses. Results Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another’s cultures to achieve the transformation towards PHC has been central to the PCNs’ survival and success. Conclusions Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another’s cultures; and how best to support the transformation of a system while delivering care locally.