FHTs and NPLCs have matured over the 5 – 9 years that each organization has been in existence. Contracts between MOHLTC and FHTs expire on March 31, 2016, with this comes the opportunity to develop a much more mature and meaningful approach to governing these organizations, from the Ministry and through to the board of each FHT and NPLC, to deliver high-quality primary care and improve the health of people in the communities served.

As the representative voice for FHTs and NPLCs, AFHTO’s board, committees and staff embarked on a process with the membership to identify the key principles to guide this journey toward more mature relationships, including contracts that support high-quality comprehensive interprofessional primary care.  To date the process has included:

1. Initial issues identification and concept development through the Governance + Leadership (GLAC) and ED (EDAC) Advisory Committees
2. Survey e-mailed to the board chair, lead MD/NP and executive director of each AFHTO member organization (115 responses received between Sept. 10-29, 2014)
3. Leadership session held immediately before the AFHTO conference (about 180 attended on Oct.15, 2014)
4. Resulting from steps 2 + 3, this report-back to the membership on principles + priorities to guide AFHTO’s work

Guided by the principles and priorities that have emerged from the AFHTO membership, this journey will continue with on-going:

• Oversight by AFHTO board
• Advice from GLAC, EDAC and soon-to-be-established Lead MD/NP Council
• Updates and further consultations with the full AFHTO membership as the process unfolds

1         Principles to guide our way forward

1.1      Principles for governance of primary care organizations

Given the strong level of support indicated through the survey of leaders of AFHTO member organizations AFHTO adopts the following governance principles: FHTs and NPLCs are not-for-profit corporations in a health system mandated to provide appropriate, equitable, sustainable care.  Their boards:

• Are accountable to the patients, funders and members of their organization.
• Ensure their organizations are appropriately managed and advocate for appropriate resources so that patients can access high-quality comprehensive care that is sustainably delivered and strives to meet patient and public expectations.
• Ensure the culture of their organization supports development of high-functioning interprofessional teams.
• Provide leadership to harmonize and optimize policies and practices for effective and efficient teamwork within the organization and with other entities contributing to the health and health care of the organization’s patients and community.
• Provide leadership and collaborate with other organizations to spread best practice and encourage growth in capacity so that all Ontarians can have access to high quality interprofessional comprehensive primary care.
• Ensure that patients and community members are engaged in the development of programs and services.

These principles describe the more mature relationship the leaders of AFHTO’s member organizations want to have with their funders, members, staff and other stakeholders. They will guide AFHTO’s work in advocacy and in developing learning opportunities and support for members to succeed in their roles as governors and leaders.

1.2      Principles for accountability and reporting to funders

The strength of the survey results also lead AFHTO to adopt the following principles for accountability and reporting to funders. These principles will guide AFHTO’s advocacy with government, on behalf of members, on development of the next set of contract templates:

• Financial and clinical reporting should minimize duplication in data collection and reporting.
• Accountability should be defined in terms of collectively agreed upon measures that reflect value delivered.
• Reporting requirements should place more emphasis on the work of the team to achieve outcomes and less on individual member activities and patient encounters.

1.3      Principles for determining accountability measures

While AFHTO members are strongly in favour of accountability and reporting based on meaningful measures, they are also cautious about how these measures will be determined. Leaders who attended the Oct. 15 leadership session provided the following guidance on principles for determining accountability measures that should be followed by AFHTO, the Ministry and any other stakeholders involved in the process:

• MOHLTC must engage in a collaborative process to define outcome measures to be used for reporting.
  • Input from providers/engagement of AFHTO membership is essential.
• MOHTLC must provide adequate support so that FHTs/NPLCs have the capacity (i.e. the people and technology needed) to collect and report their data.
• Measures must be meaningful, measurable, consistent and comparable.
  • More specifically, measures must be evidence-based, clinically important, include process and outcome, be easy-to-track on an on-going basis, clearly defined and standardized for meaningful comparisons, and aligned with other Ministry priorities and reporting requirements.
  • Measures must also incorporate patient experience, and involve patients in what the measures will be.
• The approach to accountability measurement must be sufficiently flexible to account for variation in patient complexity and their social determinants of health, in regional and rural-urban settings, and in size and maturity of teams.

2         Additional guidance received from members

2.1      Help needed to move toward accountability for outcomes

If FHTs and NPLCs are to be held accountable for meaningful outcomes, what is the evidence as to what must be in place to achieve this? Participants in the Oct.15 leadership session were presented findings from a not-yet-published study by the Ontario College of Family Physicians to identify characteristics and predictors for high performance in FHTs. The factors found to be associated with quality outcomes included:

• Strong leadership is associated with better governance and integration of FHT and Family Health Organizations (FHO).
• Team leadership promotes higher team functioning.
• Understanding and respecting practitioner scope of practice is essential to optimal team functioning.
• Co-location and effective office design impacts team functioning.
• Differential pay among co-workers as a result of dual funding creates problems in teams.

The September 2014 AFHTO leadership survey had also found that 80% of respondents agreed that “greater harmony between the physician-funded groups and the FHT-funded groups is essential to the FHTs moving forward to ensure optimal interprofessional comprehensive primary care.” Through small group discussion followed by voting on top ideas, FHT and NPLC leaders in AFHTO’s leadership session then identified their priority needs “to help strengthen team collaboration and move toward team accountability for agreed upon outcome measures.” These priorities emerged:

• The critical need for alignment:
  • Between FHTs/NPLCs and their associated physician groups
  • Among objectives of key players, including the Ministry, Ontario Medical Association and Ontario Primary Care Council
  • Among all team members, invested in a common purpose
  • Between performance and funding to encourage people to work towards clearly defined and transparent measures
• Joint accountability of physician group and FHT/NPLC to increase provider participation and engagement, and mechanisms by which such engagement is supported financially and otherwise
• Addressing system conflicts that FHTs/NPLCs are being held accountable to but have no authority over (e.g. hospital efficiency, ER visits etc.)

AFHTO is guided by the fact that some FHTs have already undertaken measures to harmonize working conditions and expectations between their physician-funded and FHT-funded groups, i.e.:

• Close to half of leadership survey respondents have:
  • Adopted one common set of HR policies
  • One ED with reporting authority over all physician-funded and FHT-funded staff
• Close to half of leadership survey respondents have:
  • A common compensation scheme for FHT-funded and physician-funded employees
  • One common employer arrangement
  • A service contract between the physician group and FHT
• Over one-third have no formal arrangements in place at all.

2.2      Basis for funding allocation

When it comes to the factors that should be reflected in allocation of funds, the leadership survey revealed:

• Solid agreement that case mix (patient complexity) is a critical factor (91% agree or somewhat agree, 3% disagree)
• Support for other factors as well:
  • achievement of performance targets (80% agree, 5% disagree)
  • geography/dispersion of services (77% agree, 5% disagree)
  • degree to which organization plays a system role (78% agree, 11% disagree)
  • number of patients enrolled (77% agree, 15% disagree)

Comments overwhelmingly pointed to the need for sufficient funding to recruit and retain staff and for greater budget flexibility. Additional comments concerned the timing for budget approvals and other needs for added funds.

2.3      Hopes and concerns regarding accountability for outcomes

The final question asked of the 180 participants in AFHTO’s leadership session was – “If we move in this direction, what are you most hopeful about, and concerned about, the next set of contract templates?” About 100 responses indicated members are hopeful that the move toward strengthened team collaboration and team accountability for outcomes would lead to:

• Improvement in outcomes (including both patient experience and provider engagement/satisfaction) and evidence of value delivered
• Improvement in funding and greater flexibility in using funds
• Greater efficiency in measurement and reporting (less duplication, less waste of time)

Another 100 responses clustered around concerns about:

• The choice of measures
• Capacity to measure
• Funding ( potential expectation to “do more with less”, consequences of failing to meet targets)
• The Ministry and other stakeholders (e.g. lack of transparency, lack of common vision, power imbalance)
• The need to be able to reflect differences among teams and the communities they serve

3         Next steps

Thank you to all of the leaders in AFHTO’s member organizations who have made their views known through the September survey and/or the October 15 Leadership Session.  Guided by the principles and priorities that have emerged from the AFHTO membership, this journey will continue with on-going:

• Oversight by AFHTO board
• Advice from Governance + Leadership Advisory Committee, Executive Director Advisory Council and soon-to-be-established Lead MD/NP Council
• Updates and further consultations with the full AFHTO membership as the process unfolds.

AFHTO members are welcome to send further comments and ask questions at any time:

• Regarding work toward new contract templates, to Executive Director Angie.Heydon@afhto.ca
• Regarding the governance and leadership of FHTs and NPLCs, to the Provincial Lead for the Governance and Leadership Program, Bryn.Hamilton@afhto.ca
• Regarding AFHTO’s work to advance measurement capacity, to the Provincial Lead for the Quality Improvement Decision Support Program, Carol.Mulder@afhto.ca
• General questions/comments, to info@afhto.ca.