Enhancing Team Functioning in Ontario Community Health Centers

Explore the importance of team function in Ontario Community Health Centers (CHCs) and how it impacts quality of care delivery and innovation in primary care. Understand the dynamics of inter-professional teamwork, the multi-faceted concept of team function, and the potential for interventions to improve team effectiveness. Previous research highlights the need to focus on staff perceptions and organizational features to optimize team functioning in CHCs.

• Team Functioning
• Community Health Centers
• Primary Care
• Inter-professional Teamwork

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1. Different strokes for different folks? Staff perceptions of team functioning in Ontario Community Health Centres Jennifer Rayner Laura Muldoon Ontario Community Health Research Rounds January 21, 2015

2. Details COI - Investigators are employees of CHCs Funding from University of Ottawa Department of Family Medicine Research Funding Program Ethics from Ottawa Health Sciences Research Network and Bruy re Continuing Care

3. What are PC teams? Inter-professional teamwork in PHC is a priority in Canada2 Know more about who team members are than what they do or how they work together.3 Membership of PC teams vary widely depending on the setting2 Care is by the integrated activities of clinical and non-clinical members of (PC) teams 4

4. What is team function? Multi-faceted concept and includes the following5: Processes and psycho-social traits of the team Links a team s task design (types & features of the tasks) Membership of the team Team effectiveness

5. Is team function important? Quality of team function linked to innovation and effectiveness in PC6, technical quality of care.7 Quality of team function may have more influence over clinical behaviors in PC than individual provider or practice characteristics.8 Aspects of team function can be improved by certain interventions.9

6. Why look at CHC teams? Quality of primary care delivered in CHCs is equivalent or superior to that in other PC models in Ontario.2, 11,12,13 ICES CHC study If you ve seen one CHC, you ve seen one CHC Provincial tour different feel to the teams Little is known about CHC PC team function Quebec community-governed practices (some similar to Ontario CHCs) had lower scores for team climate than professionally-governed practices14

7. Previous Research Results Staff Groups & Teams Ontario: admin staff reported suboptimal team climate more than GPs.14 US CHC physicians dissatisfied with high workloads and administrative management.15,16 No literature on how other team members view team functioning Organizational Features & Teams Leadership, professional governance, solo practice, certain team cultures are associated with better team function No association previously found with size of the team or number of sites (in PC)

8. Our Questions... How do CHC staff rate the functioning of their teams? Are there differences between different groups of staff in how team function is perceived? Are there differences between different CHC organizations? Are there organizational features which can explain the differences?

9. Methods Cross-sectional, part of proposed larger study Ethics OHSRN/Bruy re REB All 75 CHCs invited PHC director completed organizational survey ED distributed on-line survey to PC staff ``any person who provided or supported the provision of clinical care on a regular basis (including administration & reception)

10. Organizational Survey Adapted from CIHI Number of sites, staffing, size, priorities, means of communication, rurality, years of operation, patient demographics

11. Staff Survey Descriptive (professional role, full-time status, number of years employed at the CHC , working off- site from the main clinic) 3 different scales

12. Team Climate Inventory Team Climate: shared perceptions of policies, practices & procedures within team Short, validated 14 item version Vision Innovation Participative safety Task Orientation

13. Organizational Justice Assesses perceptions of fairness, equity & respect Procedural Justice (PJ) 7 items (perceived fairness) Procedures are in place to generate standards so that decisions can be made with consistency Interactional Justice (IJ) 6 items (politeness, dignity & respect) Primary health care team members consider your viewpoint.

14. Organizational Citizenship Behaviour Perceptions of the presence of work related behaviors that are: discretionary not related to the formal reward system in the aggregate promote the effective functioning of the organization.20 13 items Help each other out if someone falls behind in his/her work

15. Analysis Staff characteristics Responses stratified by staff group (manager, physician, NP, registered nurse, medical secretary, allied health, counselor, outreach, admin assistants) One-way Anova to determine overall difference in team climate, organizational justice and citizenship behaviour between the different provider groups. Bonferroni posthoc analysis based on apriori hypothesis Organizational characteristics Linear regressions relating organizational features with the various measures of team function

16. Overall Results 58 CHCs (77.8%) 674 staff physicians, NPs, nurses 57% of the respondents Excluded system navigators due to low numbers

17. 100 CHC Staff (Ontario) 90 80 70 60 Yrs x10 50 % FT (%) 40 30 20 10 0 NP MD Nurse SW Allied Out MOA AA Mgr

18. Results One way ANOVA significant difference between staff groups on mean scores for: Procedural Justice (p= 0.01) Total TCI (p=0.03) Innovation subscale of TCI (p=0.011)

19. Team Climate Inventory 5.6 5.5 5.4 5.3 5.2 5.1 5 4.9 4.8 4.7 4.6 NP Physician Nurse SW Allied Outreach Sec AA Manager TOTAL

20. Organizational Justice 5.6 5.4 5.2 5 4.8 4.6 4.4 4.2 Physician NP Nurse SW Allied OutreachSecretary AA Manager TOTAL

21. Organizational Citizenship Behaviour 5.4 5.3 5.2 5.1 5 4.9 4.8 4.7

22. Differences between groups

23. PJ - Organizational level results

24. Organizational features & team function Association ONLY between higher number of sites and lower team function. (TCI and OJ p<0.05) The different measures of team function were highly correlated at the organizational level

25. PJ 1 0.9 PJ IJ OJ TCI OCB 0.8 0.7 0.6 0.5 0.4 OCB IJ 0.3 0.2 0.1 0 TCI OJ

26. Discussion TCI ratings similar to other Canadian PC studies.7,21 Citizenship behaviour and organizational justice within the range of results reported in other settings.8,22, 23 Similar views of vision and mandate of CHC, work well together, help each other Differences between staff types for TCI, innovation and PJ Different expectations? TCI link to patient-reported access, continuity, quality of diabetes care, patient satisfaction BUT not in every study. Recent Quebec study modest association between TCI and technical quality of care

27. Procedural Justice NPs & physicians significantly lower than admin staff & nurses PJ linked to improved quality of diabetes care8, better glycemic control 22more job satisfaction among physicians and nurses 26,27 Perceived injustice linked with poorer quality, lower productivity of health care work 28,29 stress-related disorders among staff30

28. Why the different PJ ratings? CHC model managers manage Providers don t Many managers MAY be from nursing background? NP and physician have different expectations? MD unhappy about management in US CHCs NP unhappy about division of labour on team? NP unhappiness about wages? Part-time employees rate team higher, more resistant to change24,25 Longer duration of employment effect? Medical secretaries left many questions unanswered questions too clinical? Or didn t feel they were part of the team?

29. Organizational features CHCs have many organizational features in common, such as community governance, inter-professional teams, model for remunerating staff and leadership model. Staff of a team spread across many sites may not feel cohesive, may rate TCI and OJ lower for the entire team. (Future: assess as separate entities the teamlets that make up multi-site teams.)

30. Strengths/Weaknesses 77% CHCs participated Lots of staff BUT no denominator Validated instruments

31. Conclusion All staff had positive ratings of team climate, organizational justice and organizational citizenship behaviours Physicians and NPs had lower ratings for procedural justice. Procedural Justice has been shown to be very important in other settings, and may be amenable to improvement through interventions. The only Org feature relating to function was number of sites

32. Next steps Qualitative study Working on defining the question Differences in PJ due to expectations of NP& MD... systematic silencing...or both? Will choose high and low performing sites for interviews Staff of different types

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