Project Purpose
The purpose of the following case studies is to support the provision of high quality, patient-centred care by fostering FHT-physician team work and collaboration amongst primary care organizations within AFHTO’s membership. Research evidence suggests that primary care is most effective when there is a long-term, continuing relationship with physicians and/or nurse practitioners, working as full collaborators in an interprofessional team. However, the majority of current FHT-physician relationships are based on loose partnerships and reliant on the ‘goodwill’ of each party.
Introducing mutually beneficial and adaptable tools such as relationship frameworks, memorandums of understanding (MOUs), or contracts may facilitate a clearer understanding and alignment of duties, roles and responsibilities; demonstrate appropriate attention to risk management considerations; and promote team culture and excellence in team performance.
In February 2017, AFHTO put out a call for volunteer FHTs to share their approaches to collaboration between physician groups or individual physicians and the FHTs. Specifically, FHTs were asked to share whatever tools/policies/documents/contracts/frameworks they leverage to encourage collaboration and FHT-physician team work. Seven FHTs responded and the executive directors were interviewed. Case studies were developed based on four FHTs and their lead physicians were also interviewed. The four case studies were selected to showcase the variation and unique approaches teams can utilize to foster FHT-physician partnerships.
No one single model can be effectively replicated across all FHTs; the intent of the case studies is to prompt FHT Boards to have open discussions with their physician groups on possible mechanisms to enhance working relations and support team harmonization in a mutually beneficial manner. The FHTs interviewed included:
- East GTA FHT, Toronto
- North York FHT, North York
- Northeastern Manitoulin FHT, Manitoulin Island
- Peterborough FHT, Peterborough
- Queen Square FHT, Brampton
- Thames Valley FHT, Southwest Ontario
- Village FHT, Toronto
Common Themes of Success
There were several themes that emerged as common to all FHTs interviewed.
Leadership
Leadership approach and influence were overwhelmingly the strongest factors determining the strength of relationships within FHTs. The “Leadership Triad”, comprising the FHT Executive Director, the FHO(s) Lead Physician acting on behalf of the FHO(s), and the Board Chair, sets expectations and influences culture. Each organization interviewed identified solutions that fit their context and needs to support collaboration between physicians and the FHT. Ultimately, all are working to influence a collaborative organizational culture. Rigorous leadership structures and clearly defined expectations with supporting documentation aids physicians, integrated healthcare professional (IHP) staff, administrators and executives to feel supported, understand expectations, and act appropriately within the context of the FHT. Whenever possible it is best to develop shared documents/ agreements/ policies/ etc, to aid in unifying the partnership.
Engagement
Another common theme was the importance of engagement of all interested parties when change is required. Change may include the development of a process or directive, creation of a contract or relationship framework, any kind of reorganization, addition of a new FHO to an FHT, etc. Most people are uncomfortable with change at some level and this discomfort is increased when the reasons for change are not effectively communicated or understood. This theme was addressed from various angles. One interviewee from a large FHT shared that when a FHO expresses interest in joining a FHT, it is important to do the due diligence and ensure that all physicians are on board. Taking the time to educate physicians on what they can expect and what will be expected of them will ultimately save time for everyone and start the relationship on smooth ground. Another example of engagement was the development of an FHT-physician contract. By encouraging substantive input and feedback at various stages of the development process, individual physicians and FHO groups had the opportunity to ask questions and understand the elements and benefits of the contract for all parties. When people are included in the reasons and need for change, they are much more likely to buy-in and support the change.
Education Breaks Down Barriers
When introducing change, many FHTs reported that they have found it beneficial to actively educate stakeholders in the language and reasons behind the change. As an example, when North York FHT was developing its Physician Contract, many physicians were uncomfortable with some of the legal language. Once that language was explained and the ramifications clarified, the discomfort went away and physicians came to favour the contract.
Consistency Cultivates Collaboration
When groups have a common goal and a clear understanding of how each contributes to the success of reaching it, it is much easier to work together to reach the goal. From an FHT perspective, medical directives are an excellent example of documentation that reinforces consistency of action and collaboration in best serving the patient. Medical directives clearly define scope of action for involved practitioners. Everyone understands who does what and over time they come to trust that colleagues will act in a consistent and collaborative manner.
Case Studies
Location: North York Region
Demographic: Large urban
FHT Context: Formal Physician Contract
Case Summary: The North York Family Health Team (NYFHT) is a large, urban, multi-site academic/community FHT that has to deal with the challenges of an expansive organization. The Physician Contract, as part of a Board policy, is a signed agreement that communicates a clear understanding and alignment of duties, roles and responsibilities between the individual physicians and the FHT. Designed to be a neutral grounding document to support both parties and to align with the Board’s strategic direction and NYFHT bylaws, the development of the Contract created an opportunity to: enable more efficient provision of NYFHT Services; facilitate clear understanding and alignment of duties, roles and responsibilities; and, demonstrate appropriate attention to risk management considerations, e.g., PHIPA.
Location: South-west Ontario
Demographic: Large rural and urban FHT
Context: FHO-FHT Relationship Framework
Case Summary: The Thames Valley Family Health Team (TVFHT) is a very large FHT that spans both urban and rural catchment regions. As the FHT grew, they found that there was a significant range of expectations and motivation among FHOs and individual physicians for joining the FHT. The Relationship Framework was created to document a common understanding of roles and requirements of physicians and their staff, the FHT and its staff and executive, and the Board of Directors. Because the Relationship Framework is not signed, it does not have legal weight; rather is used as a reference document to set expectations, reinforce consistency and address challenges as they arise.
Location: Brampton
Demographic: Small suburban FHT
Context: Common Planning Approach
Case Summary: Queen Square Family Health Team (QSFHT) believes in sound organizational structure and communication through the use of medical directives, policies, and procedures to support physicians and IHPs in their respective roles. New documents are created through a common planning approach. When expectations and accountabilities are clearly outlined, all clinicians understand their roles and are empowered to act with confidence. Consistency of practice creates trust; trust drives collaboration.
Location: Manitoulin Island
Demographic: Small Northern FHT
Context: Close Working Relationships
Case Summary: The Northeastern Manitoulin Family Health Team (NEMFHT) is a northern Ontario FHT. It encompasses a Rural and Northern Physician Group Agreement (RNPGA), managed by the Little Current Medical Association (LCMA), which consists of a small, tightly-knit group of physicians and staff who have worked together to serve the region for a long time. Upon establishment, the FHT was mindful of this existing close working relationship and was careful to maintain this dynamic of trust and collaboration. The FHT executive worked to reinforce this dynamic, and integrated new FHT staff slowly and purposefully to address identified gaps and needs in services to better deliver care to the community.
Collaboration Resources
The following templates represent documents or processes employed by the FHTs interviewed for this project. Feel free to adapt or alter these as necessary to fit the needs or your FHT.
Memorandum of Understanding
A Memorandum of Understanding (MOU) describes a bilateral or multilateral agreement between two or more parties. It expresses a convergence of will between the parties, indicating an intended common line of action. The MOU provides documentation that demonstrates the parties have consulted upon and coordinated the responsibilities of their agreed activities. The following elements may be considered when constructing an MOU:
- Describe each partner
- State the purpose of the MOU
- Clearly describe the agreed upon roles and responsibilities each party; roles and responsibilities should align with project goals, objectives and target outputs of the collaboration
- Identify the staff (by position) responsible for completing specific responsibilities
- Describe how the collaboration/partnership benefits the project
- May describe resources each party contributes to the endeavour, for example, time commitment, in-kind contributions, grant funds, office space, staff, training,
- May include a statement about which party accepts full responsibility for the performance of the collaboration
The MOU must be signed by all parties. Signatories must be officially authorized to sign on behalf of the parties and include title and agency name. Click here to download a customizable MOU template [MS Word Document]. Example: North York FHT has created a Physician Contract [PDF] that is a signed agreement which communicates a clear understanding and alignment of duties, roles and responsibilities between the FHT and its associated physicians. Designed to be a neutral grounding document to support both parties, the Contract is meant to clarify FHT and physician responsibilities; create standardization of policies and procedures across sites; address PHIPA and facilitate the sharing of data; guide conflict resolution; and meet legislation and accountability.
Relationship Framework
The Relationship Framework [PDF] was created by the Thames Valley FHT as a means to describe the expectations and requirements of physicians and their staff, the FHT and its staff and executive, and the board of directors. The Framework includes corporate accountabilities; accountabilities for affiliated physician groups; comments on funding agreements; commentary on patient-centred care, medical professionalism and behavioural standards; and a conflict resolution process. Because the Relationship Framework is not signed, it does not have legal weight; rather is used as a reference document to set expectations, reinforce consistency and address challenges as they arise.
Accountability Management System
Queen Square FHT has developed a common planning approach supported by a program planning tool called the Accountability Management System, which serves as a template framework to guide the development process of medical directives, programs, procedures, etc. and create standardization across documentation. QSFHT’s aim was to create a framework that outlines the structure and process regardless of the task at hand. The Accountability Management System is a web-based tool which incorporates common themes of Goals, Services, Objectives, Outcomes and Indicators. It simplifies and clarifies the development process and reduces the barrier to address gaps in a timely manner, as they are identified. The Accountability Management System is an enabler for collaborative work, so that the different providers are clear on program plans, and there is a common language/reference to facilitate the collaboration. Click here to access a sample document created according the Accountability Management System [PDF].
Vision and Values
A sample Vision and Values [PDF] has been provided by East GTA FHT. The Vision and Values are the foundation of the organization and its culture, and are taken seriously. They are leveraged during the hiring process to ensure that each successful candidate understands and is committed to uphold them, as cultural fit is a top priority at East GTA FHT. East GTA FHT acknowledges the importance of its Vision and Values through incorporation into it By-Law No. One: A By-law relating generally to the conduct of the affairs of the East GTA FHT Governance.
“Without limiting the generality of the foregoing, the Board’s key functions are… (b) to help develop the Corporation’s vision and values, and to participate in generative discussion;”
“The Chair shall… iv. in collaboration with the Lead Physician and Executive Director, champion the vision and values of the Corporation;”
“The Lead Physician shall… v. in collaboration with the Chair and Executive Director, champion the vision and values of the Corporation;”
East GTA GHT’s Executive Director, Sudin Ray, elaborates on that; “A shared set of values help the FHT to deal with conflict, as it happens and when it happens”. The shared values have been used a few times as a foundational document by the Board to deal with infractions in early years, both at the FHT level as well as with the sister FHOs. Having a set of values is not that difficult to establish; East GTA FHT finds the real challenge to be creating a culture that embraces these values in the day to day affairs of the corporation, as this requires commitment and hard work.
Service Level Agreement
Peterborough FHT was a first-wave FHT and still operates using flow through transfer payments. They provided a sample Service Level Agreement [PDF] that they find useful in defining responsibilities and tasks that are required by the FHT and FHO throughout the year in exchange for monthly funds flowed through to the FHO. The completion of these tasks allows the FHT to meet their requirements per the funding agreement with the Ministry of Health and Long-Term Care as well as legal requirements as the employer of the FHT Interdisciplinary Health Professionals.