What Makes a Successful
Interprofessional Team?
Views from Health Service Providers in
Northwestern Ontario
July 2009
The opinions expressed by the participants in this study are theirs alone and are not
meant to represent the opinions or official positions of the North West LHIN
North West Local Health Integration Network
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Acknowledgements
The author of this report, Ian Newhouse, would like to acknowledge and thank those
individuals that made this initiative possible. At the top of the list would be all of the
participants that took part in the focus group or key informant interviews. Without exception,
you gave generously of your time, your expertise, your insights and opinions. A lasting
impression of the many interviews is the passion you bring to your work and the desire to
bring about positive healthcare/promotion change at both the individual or system level. This
work was supported conceptually, financially and editorially by the North West Local Health
Integration Network. In particular, Kristin Shields was an invaluable resource throughout all
aspects of the project. Questions or comments regarding this report can be directed to Ian
Newhouse, Ph.D. at [email protected]
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Table of Contents
1.0 Executive Summary ................................................................................................... 5
2.0 Purpose....................................................................................................................... 8
3.0 Significance ................................................................................................................ 8
4.0 Definitions................................................................................................................... 9
5.0 Methods ...................................................................................................................... 9
A. Recruitment procedures................................................................................ 9
B. Interview procedures ................................................................................... 11
C. Data analysis ................................................................................................ 12
6.0 Limitations ................................................................................................................ 12
7.0 Results and Discussion........................................................................................... 13
Interpersonal relationships ................................................................................... 14
A. Willingness to collaborate........................................................................... 14
B. Trust .............................................................................................................. 16
C. Mutual Respect............................................................................................. 17
D. Communication ............................................................................................ 19
Conditions within the organization....................................................................... 20
A. Organization’s philosophy .......................................................................... 20
B. Administrative support ................................................................................ 21
C. Team Resources .......................................................................................... 22
C.1 Time............................................................................................................22
C.2 Human ........................................................................................................23
C.4 Financial.....................................................................................................23
D. Coordination and Communication Mechanisms ....................................... 24
D.1 Technology ................................................................................................24
D.2 Case Conferencing and other means to communicate with the
community........................................................................................................26
D.3 Communication role of the NW LHIN .......................................................27
D.4 Program management...............................................................................28
D.5 Collocation of health professionals .........................................................28
D.6 Navigation through the health system .....................................................29
E. Organizational structure .............................................................................. 31
E.1. Silos...........................................................................................................33
Systemic determinants .......................................................................................... 34
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A. Educational system ..................................................................................... 34
B.1 Culture of patient centred collaborative care ..........................................37
B.2 Culture of constituents .............................................................................38
C. Professional System .................................................................................... 38
D. Social system ............................................................................................... 39
8.0 Recommendations: Wish list summary ................................................................. 40
Appendix A: Description of Focus Group Setting....................................................... 41
Appendix B: Wish List ................................................................................................... 45
References...................................................................................................................... 51
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Interprofessional Care Project
1.0 Executive Summary
The purpose of this study was to conduct an environmental scan of what interprofessional (IP)
models are being used across the North West Local Health Integration Network (NW LHIN).
This scan provides evidence related to the potential benefits of IP education (IPE) and IP care
(IPC). More importantly, this scan identifies the themes and determinants associated with
successful collaborative patient centred practice and from this the NW LHIN should be better
equipped to develop strategic plans associated with IPC.
Ten focus groups and four key informant interviews were held between January 1 and March 1,
2009. Individuals from both the health care and health education sectors were asked to
participate in focus groups or as key informants. Efforts were made to attain input from a broad
range of health professions, health care organizations and geographic region within the North
West LHIN.
The focus groups were comprised of:
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Anishnawbe Mushkiki Aboriginal Community Health Centre (Thunder Bay)
Geriatric Interprofessional Interorganizational Collaborative
Maternity Centre of Thunder Bay Regional Health Sciences Centre
NorWest Community Health Centre
NW LHIN Health Human Resources Roundtable
St. Joseph’s Care Group (Thunder Bay)
Sioux Lookout Meno-Ya-Win Health Centre
Sunset Country Family Health Team (Kenora)
Take Heart Coalition (Thunder Bay)
Lakehead University instructors of IPE
In total (focus groups plus key informants) 66 individuals were interviewed after informed
consent.
The three main questions of the interview guide were:
1. How will IPE and collaborative patient centred practice make a difference?
2. What are the main impediments to progress?
3. What and how could progress be made in regards to IP care?
These were posed in an appreciative inquiry mode. For example: “think of your best experience
with IPC or IPE”, “Why was this the best?”, “What wishes would you have for IPC or IPE?” and
“How may we bring this about?”
Transcripts of the interview material were reviewed to extract common themes and relationships
which were interpreted in light of the model below (adapted from work of San Martín-Rodríguez
et al., (2005)). This adaptation shows how interpersonal relationships provide the most direct
influence on successful collaborative patient centred practice, with a broader context being the
conditions within the organization which in turn are housed in the broader context of systemic
determinants.
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Figure 1: Model to describe the determinants of collaborative patient centred practice. Blue =
Interpersonal relationships; Orange = Conditions within the organization; Green = Systemic determinants.
An interactive model which allows the reader to drill down into each determinant can be accessed at:
http://www.northwestlhin.on.ca/IPC/index.html.
Interpersonal relationships included a willingness to collaborate, trust, mutual respect and
communication. A willingness to collaborate could be viewed as the precipitating factor for IPC
to take place as both patient and provider need to weigh the merits of collaborative care. Three
major patient benefits included:
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Convenience
Multiple perspectives improving the quality of care
Better access
Motivating factors for care providers to engage in IPC were:
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A belief in the end goal that quality of care is indeed improved with IPC
The opportunity for IPE, which is integral to IPC
A belief that IPC was efficient and cost effective, particularly with complex patients
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Trust (that others will do what is expected of them) was both an enabler and a result of a
collaborative environment. Mutual respect was reflected in knowing and valuing each others
roles. Communication amongst all stakeholders on an IPC team (and in particular with the
patient) is essential. Language was a common barrier with First Nation peoples and the
important role of interpreters on IPC teams was reinforced.
All of the interpersonal relationships that guide collaborative patient centred practice are
impacted (either positively or negatively) by conditions within the organization. These conditions
can be categorized as dealing with the organization’s philosophy, administrative support
(including leadership), team resources, coordination/communication mechanisms, and
organizational structure. Common organizational philosophy themes in the settings interviewed
include: Value placed on patient centred-ness, prevention/health promotion, collaboration and
continuing education.
While administrative support could range from administrative assistance to a leadership position
(and both ends of the spectrum were highly valued), it was generally administrative leadership
that generated discussion amongst the focus groups. It was felt that this individual should be a
champion of IPC and/or IPE and should thus provide proactive leadership with a vision to drive
organizational philosophy. He/She would need to be courageous to take chances, to do the right
thing, to pull professions together, to create change and to engage the First Nations. He/She
would need to be creative in allocating resources, finding new solutions and getting around
some bureaucratic bylaws.
Compelling, but context specific, cases can be made for increased time, human, space and
financial resources, with the bottom line argument being that investment in IPE and IPC will
likely improve patient care in a cost efficient manner.
Essentially all consumers or providers of health education and/or care need to be able to
communicate (meaning both sending and receiving messages) clearly and efficiently.
Communication is only successful when both the sender and the receiver understand the same
information as a result of the communication. The degree to which this is accomplished rests on
the communication skills (part of interpersonal relationships) plus the mechanisms in place that
can facilitate the transfer of information. Although a communication mechanism(s) could be
identified in every IPE or IPC story, some common themes included: technology, case
conferencing, program management, collocation of health professionals, communication to the
broader community, and health system navigation.
Four broadly defined systems (educational, cultural, professional and social) make up the outer
ring of determinants of collaborative patient centred practice. Proponents of IPC see the need to
make IPE and IPC even more inextricably linked (i.e. practice settings need to be more
integrated into education settings and vice versa). Moreover care providers (with patients
themselves being part of the care team) should simultaneously be taking an explicit teaching
and learning role, so there is a culture of teaching, learning and researching in care settings.
Some general statements about the education system included:
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Everyone learning, practicing or managing in the health sector needs ongoing IPE
Responsibility for IPE is shared across post secondary institutions in partnership with
health care institutions, the LHINs and community agencies
IPE/IPC competencies should encompass cross cultural training, leadership
competencies, communication and interdisciplinary decision making skills
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
All partners should use the tools at their disposal to enhance IPE, with experiential
learning being key.
The cultural system was mentioned in two contexts: The need to develop a culture of patient
centred collaborative care and the need to be sensitive to the culture of our constituents (often
remote, rural and First Nations).
The major theme that related to the professional system was that of silos and turfism.
Professional bodies, by setting accreditation standards and scopes of practice directly impact
the education and practice of health professionals. Professionalization has historically run
counter to the development of IPC as it has placed higher priority on autonomy and control than
collegiality. This may point to a root cause (but also a strategic remedy) of professional turfism.
The social factors that were mentioned during the interviews were power differences (hierarchy)
between different professionals and the social status that makes up the clientele in some health
centres.
Numerous wishes were generated and these could help set the vision for where IPE and IPC
could go in Northwestern Ontario.
2.0 Purpose
The overarching purpose of the North West Local Health Integration Network (NW LHIN) is to
provide an integrated health system to improve the health of Ontarians through better access
to health services, coordinated health care and effective and efficient management of the health
system at the local level. Within this broader context, the purpose of this study was to conduct
an environmental scan of what interprofessional models are being used across the NW
LHIN. This scan will include barriers, opportunities, learning needs, best practices and projected
health human resource needs.
3.0 Significance
A review of the literature on interprofessional care (IPC) would indicate that IPC may:
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Improve access and shorter wait times for patients/clients
Improve safety and better patient outcomes
Instill greater public confidence in the system
Decrease morbidity
Lower costs of care
Provide greater emphasis on prevention and social determinants of health
Allow greater health care provider satisfaction
Enhance recruitment and retention of health care professionals
The environmental scan, as proposed in this project, should provide further evidence related to
these potential benefits and in particular if they hold true in selected models of IPC in NW
Ontario. More importantly, this scan should identify the themes and determinants associated
with successful collaborative patient centred practice and from this the NW LHIN will be better
equipped to develop strategic plans associated with IPC.
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4.0 Definitions
Integrated health system:
adheres to principles of community engagement, cooperation and coordination, equity and
diversity, accountability and transparency, and sustainability. NW LHIN Integrated Health
Services Plan
Interprofessional care (IPC):
is the provision of comprehensive health services to patients by multiple health caregivers
who work collaboratively to deliver quality care within and across settings.
Interprofessional care can be systemically implemented to assist in health care system
renewal and improved sustainability. HealthForceOntario
Interprofessional Education (IPE):
is when two or more professions learn with, from and about each other to improve
collaboration and the quality of care. Centre for the Advancement of Interprofessional
Education
Environmental Scan:
is a key component of planning processes and provides the foundation for the
development of strategic, financial and performance plans. The scan describes empirically
how demographic, political, economic, social, cultural, legal, and technological trends
affect the issue at hand. Ministry of Finance
Appreciative Inquiry (AI):
is an organizational development process or philosophy that engages individuals within an
organizational system in its renewal, change and focused performance. It is now a
commonly accepted practice in the evaluation of organizational development strategy and
implementation of organizational effectiveness tactics. Wikipedia
5.0 Methods
This project was conceived in the fall of 2008. From September through December the scope of
the investigation was clarified, relevant literature was reviewed, an appropriate methodology
was selected, questions were honed and piloted, and ethics approval was sought. Ethics
approval was attained from three institutions: Lakehead University, St. Joseph’s Care Group
and the Thunder Bay Regional Health Sciences Centre.
A. Recruitment procedures
Throughout January and February, 2009, ten focus groups and four key informants interviews
were held. Individuals from both the health care and health education sectors were asked to
participate. Efforts were made to attain input from a broad range of health professions, health
care organizations and geographic region within the North West LHIN. Potential focus group
participants were purposefully sampled in that the North West LHIN has contact information of
various health professionals and health educators in the region through their previous
community engagement strategies. Letters of invitation were sent to focus group “leads” who in
turn sent invitation letters to 8-25 individuals within their organization. For convenience,
interviews typically took place at a meeting room of the health organization. Each focus group
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interview lasted 60-90 minutes and each key informant interview lasted 45-60 minutes. All
interviews were audio recorded with the participants’ permission as outlined in the consent form.
Focus group interviews preceded the recruitment of key informants. Due to the size and
complexity of the health and education sectors in Northwestern Ontario, there were gaps in
attaining a comprehensive picture of IP models. To address these gaps, the perspectives of key
informants were sought. Key informants were again identified through the North West LHIN. The
possible questions for key informants were the same as those posed to the focus groups.
The focus groups were comprised of:
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Anishnawbe Mushkiki Aboriginal Community Health Centre (Thunder Bay)
Geriatric Interprofessional Interorganizational Collaborative
Maternity Centre of Thunder Bay Regional Health Sciences Centre
NorWest Community Health Centre
NW LHIN Health Human Resources Roundtable
St. Joseph’s Care Group (Thunder Bay)
Sioux Lookout Meno-Ya-Win Health Centre
Sunset Country Family Health Team (Kenora)
Take Heart Coalition (Thunder Bay)
Lakehead University instructors of IPE
In total (focus groups plus key informants) 66 individuals were interviewed after informed
consent. A rough1 tabulation of professional training indicated the following professions were
represented (to avoid potential identification, the number of participants is only noted when
there were 5 or more:
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Bioethicist
Dietician/Nutritionist
Educational Consultant
Family Physician = 6
Kinesiologist
Master in Public Health
Midwife
Medical Secretary/Administrative Assistant
Nurse (RPN/RN/BScN) = 11
Nurse Practitioner = 5
Occupational Therapist
Outdoor Recreation
Paramedic
Physiotherapist
Ph.D. (Kinesiology)
Ph.D. (Outdoor Recreation)
Ph.D. (Sociology)
Psychiatrist
Psychologist
1
This information was mainly gleaned from the verbal introductions provided at the start of the interview
session and a few people didn't provide educational background while other people have multiple
degrees.
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Social Work = 7
Speech Language Pathologist
Student (Nursing)
A rough categorization into front-line care provider versus management (some people are both
and some are neither (i.e. secretarial support, university instructor)) indicated the following:
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Front-line = 30
Middle management/coordinators = 20
Senior management = 7
B. Interview procedures
The interview guide, which was used for both focus groups and key informants, had three main
questions and these were posed in an appreciative inquiry mode. Appreciative inquiry (AI) was
chosen as it was suspected that success stories would be found in the groups or individuals
interviewed. In line with AI, it was anticipated that by focusing on what works, rather than trying
to fix what doesn’t, participants would envision a future that fosters positive relationships, builds
on successes and enhances the capacity for collaboration and change. In essence then, by
using AI, the scope of the project exceeded the objectives of an environmental scan as
engagement in the interview process may have sown the seeds of implementation. Elements of
AI can be noted in the questions below where participants are asked to “think of your best
experience with IPC or IPE”, “Why was this the best?”, “What wishes would you have for IPC or
IPE?” and “How may we bring this about?”
Research question #1:
How will IPE and collaborative patient centred practice make a difference?
Introductory statement: One goal of this study is to gain a better understanding of how IPE and
collaborative patient centred practice make a difference. Perhaps a way to get the ball rolling
would be if you could think of the best experience you have had with IP care or education. In
other words, what experience are you the most proud of?
Follow up: Why was this the best experience?
Research question #2:
What are the main impediments to progress?
Introductory statement: Perhaps building on our initial question, what have been some of the
challenges you have overcome with your “best” experience and what challenges remain.
Research question #3:
What and how could progress be made in regards to IP care?
Introductory statement: We are really getting down to pragmatic solutions with this question.
Perhaps you could think of three wishes you have for IP care or education and brainstorm on
how “we” may bring this about.
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C. Data analysis
Transcripts of the approximately 20 hours of interview material were reviewed to extract
common themes and relationships. In order to describe and understand these
themes/relationships an attempt was made to depict these in a model. A draft report will be
shared with the NW LHIN and study participants. Feedback from this will be used to prepare the
final report.
6.0 Limitations
1. This is qualitative research and as such does not have random sampling. Instead the
sampling was purposively focused on those groups or individuals who would likely have
an expertise and positive inclination towards interprofessional care (IPC) or
interprofessional education (IPE). Future research should probe those individuals and
groups who may not have a positive bias towards IPC to produce appropriate counter
arguments and perspectives.
2. Neutrality of the interview facilitator is important in capturing accurate perspectives from
the participants. The facilitators for this research were sensitive to this and as much as
possible used impartial language to probe or move the discussion along.
3. Transcription errors can occur when the audio quality is poor (microphone too far away,
multiple speakers at once, mumbled words). This was alleviated somewhat by having
two microphones for all focus groups, listening to some phrases multiple times to confirm
what was said and having a note taker (in addition to the interviewer) present at most
focus groups.
4. The tone in which things are said can affect their meaning and hence the interpretation.
As the researcher was present at all interviews and transcribed the interviews himself
the potential to disregard tone was lessened. The points made in 2-4 are all threats to
validity of the research. To counter this threat (i.e. misinterpretations) a member check
will be done as a draft of the report will be given to members of the sample in order to
check the authenticity of the work. Their comments serve as a check on the viability of
the interpretation.
5. While synthesizing approximately 20 hours of interview material into a thematic model
can help identify important themes and relationships, it does run the risk of
oversimplifying what is no doubt a highly nuanced and complex area of inquiry.
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7.0 Results and Discussion
Figure 1: Model to describe the determinants of collaborative patient centred practice. Blue =
Interpersonal relationships; Orange = Conditions within the organization; Green = Systemic determinants.
An interactive model which allows the reader to drill down into each determinant can be accessed at:
http://www.northwestlhin.on.ca/IPC/index.html.
The model above was adapted from the work of San Martín-Rodríguez et al., (2005). This
adaptation shows how interpersonal relationships provide the most direct influence on
successful collaborative patient centred practice, with a broader context being the conditions
within the organization which in turn are housed in the broader context of systemic
determinants. This model also borrows from the work of D’Amour and Oandasan, (2004) in that
a ring of task complexity surrounds the patient. Indeed, the forté of collaborative patient centred
practice is the holistic care of complex patient/client condition(s). This was borne out in this
study as examples of success stories inevitably revolved around patients with complex issues.
For example one participant commented: (note that all participant quotes will appear in shaded
boxes):
They could be autistic, they could be FASD [fetal alcohol spectrum disorder], they could be
developmentally disabled, seriously mentally ill, seriously addicted, very physically ill and
actually one guy we got a bed for had all of those things, every single one of them…
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The current interest in IPC has been fueled by population aging. Population aging will have a
significant impact on the health care system in Canada as it is estimated that 82% of seniors
have one or more chronic health conditions and approximately half of those have three or more
(Wolff JL, Starfield B, Anderson G., (2002)).
Interpersonal relationships
When participants spoke of their best experiences in IPE/C there was always a strong team
atmosphere amongst the health care providers characterized by trust, mutual respect, excellent
communication skills and most importantly a willingness to collaborate. These qualities are all
inter-related; for example good communication can lead to greater trust, which can lead to
increased mutual respect which can contribute to a willingness to collaborate.
A. Willingness to collaborate
While all of the above mentioned qualities are essential, a willingness to collaborate could be
viewed as the precipitating factor for IPC to take place. As this collaboration is around patient
centred practice, the patient is an integral player on this team. It would thus take a willingness
by both the patient and the health care providers to engage in IPC. The “best experience”
stories of the participants were followed by the question; “why was this the best experience?”
and the responses targeted benefits to the patient and benefits to the other health care
providers. The key motivating factors to engage in collaborative patient centred practice from a
patient’s perspective would be improved quality of care and this could arise from the
“collaborative” aspect of the care and/or the “patient centred” adjective. The box below
describes respondents’ opinions about patient benefits. Three major themes emerged and these
were convenience (with numerous mentions of a one stop shopping analogy), multiple
perspectives improving the quality of care and better access (again mentioned numerous
times). Benefits most closely associated with patient centredness are also noted here. Although
risks associated with IPC weren’t probed, three that were mentioned included a blurring of roles
and responsibilities, a perception that allied health care providers are less authoritative than
medical doctors and the chance that some patients receive too much information.
Potential patient benefits of collaborative care
One stop shopping***
 Increased convenience
 Increased access to assessment
 More efficient care
Multiple perspectives improve quality of care*
 Avoid the challenges of having to retell their story
 Less potential for missed information resulting in patients falling through the cracks
 Better able to pick up subtleties
 More informed care
 Better clinical outcomes**
 Optimizes strengths of team
 Increased ability to anticipate problems
 More proactive
 Increased understanding of full range of needs and how they interact
 Increased awareness of other conditions
 More comprehensive care
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
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More holistic care*
If interpreters part of team, then improved quality of care
Improved problem solving
Better access**
 Easier appointments with specialists
 Seamless integrated care
 Getting care faster
 Better continuity of care
 Decreased wait times**
 People can call doctor for you
 No one turned away
Patient centred benefits
 Empowerment of patient*
 Better ability to take an active role
 Sensitive care
 One person assisting with navigation
 Not lost to follow-up
 Better patient education
 Better education for prevention
Note: *indicates number of times comment repeated
In addition to the patients, the care providers need to do a cost/benefit analysis regarding IPC to
gauge their own willingness to collaborate. As this sample was drawn purposively from those
with a positive inclination towards IPC and success stories were the focus of the question, it is
not surprising the benefits noted below far outweigh the risks.
Potential care provider benefits of collaborative care
Appreciate IPE opportunities******
 Increased level of understanding
Increased optimization of other professions*
 Can cover each other: therefore increased efficiency**
 Enhanced credibility
 Easier access to other professions
 Allows one to develop expertise
 Cost effective (especially with complex/demanding patients)
Increased job satisfaction
 People feel they are contributing
 Decreased stress
 Increased morale
 Appreciate opportunity to work within broader scope
 Increased retention (recruitment still a challenge)
 Feels rewarding to be part of team**
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More moral support
Don’t feel isolated
Inspired by others
Belief in end goal [i.e. better quality of care]****
Note: *indicates number of times comment repeated
As noted in the table above, four recurring themes appeared to feed into a care provider’s
willingness to collaborate. The strongest was probably a firm belief in the end goal, which was
that quality of care is indeed improved with IPC. The opportunity for IPE, which is part and
parcel of IPC, was also a strong motivator. Regardless of whether the IPE was formalized into
workshops or was part of the informal day to day IP learning that takes place on the job, the
opportunity to learn with, from and about each other was repeatedly characterized with words
such as “hugely satisfying” or “wonderful opportunity”. Participants also believed IPC was
efficient and cost effective, particularly with complex patients and this factor weighed into their
commitment to the model. The cost effectiveness was noted in the discussions with the
NorWest Community Health Centre when the group reflected on a “success story” of a
particularly challenging and complex case.
Some might question if this one young man is worth X number of people and X number of
dollars. The LHINs might not think this is cost effective; on the other hand, that one young man
walking through the door in Emerg is going to cost a minimum $1000 bucks. So if we keep him
out of Emerg twice we have covered the cost of that care AND he becomes a productive
individual in society.
The final subtheme underlying the willingness to collaborate theme is increased job satisfaction.
This was expressed in various ways and for various reasons throughout the focus group
discussions. In more than one setting, and despite significant challenges, individuals noted that
they “loved” their job. It is no doubt a combination of motivators that drive any individual towards
a collaborative care model. On a related question one participant was asked if, in general, it was
the younger practitioners that were embracing IPE and IPC and the older ones preferring to
stick to silos. The response was noteworthy:
I thought initially when I started working in this model, I sort of made the assumption that it was
the younger folks, you know fresh out of medical school or university and they would want to be
interprofessional, and it is not to suggest that they don’t want to be. They are. But it is also the
more seasoned veterans who have been out and doing this for a while, and I put myself in that,
just because I have been doing this for 20 years that see how important this is. You know what I
mean? So it might be a little bit more difficult for some of us to change our work habits, but we
understand and appreciate how incredibly important it is that we make this shift.
B. Trust
Trust is both an enabler and a result of a collaborative environment, so it was not surprising to
see trust cited as an important ingredient in the IPC success stories. In a team environment one
needs to know the different roles of the various team members and trust that the respective
tasks are being done. One participant called it the ingredient that was either going to “make it or
break it”. A symptom of a non-trusting environment was noted by one participant when they
recalled a time where one physiotherapist would complete a discharge assessment on one day
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and on the next morning another physiotherapist would feel compelled to do it again. It was
interesting to also note that ownership was linked to trust in two very different ways. Ownership
was seen as an impediment to IPC in the following example:
The biggest [impediment] that comes to mind is just not knowing what other people’s roles are
so then it is very difficult to have that level of trust, that say in the case of an educational
program, that things are going to be done right. I think that applies to patient care so you have
to kind of let go a little bit, which is really difficult to do if you don’t know what the other role is,
so you feel you need to take ownership of it yourself because you don’t have the confidence
[that it will get done otherwise].
This can be contrasted to the positive connotations of ownership as noted below:
I think one of my most valued experiences in my clinical life was being on the acquired brain
injury team which did start from scratch, where you had a hand in planning right from scratch
and everybody started at the same time. It creates a sense of ownership and I think it creates a
sense of trust.
It would appear that ownership can play a dual role. The difference is that in a team
environment there is a collective pride and sense of ownership towards shared goals (for
example holistic care of the client), while in a non-trusting environment individual care givers
tend to take personal and exclusive ownership over the specific elements of care for which they
are responsible.
Other trust related comments were that in patient centred collaborative care, there has to not
only be trust between the various care providers, but also between the care providers and the
patient (who actually are part of the care team). This trusting relationship may need some
nurturing with team care as a nurse from a Family Health Team commented that:
…we have been challenged by patients not really wanting to see an allied health professional
for their disease condition. I think there was a couple of ladies or patients who, when we called
to book appointments, basically said they don’t really need to see you; “I go see my doctor on a
regular basis and he takes care of me”. So that in itself is a bit of a challenge. I don’t know how
prevalent that is, but we still get some of those comments.
C. Mutual Respect
Mutual respect or slight variations on that theme were commonly mentioned in the telling of
successful IPC stories. These slight variations of a mutual respect theme included topics such
as:
Related topics to mutual respect





Knowledge of everyone’s role is key* (often contrasted to the damage that disrespect or
ignorance of others roles/responsibilities can cause)
Evolving role of nursing leading to lack of clarity regarding nursing roles/responsibilities
Need to be aware of everyone’s strengths and weaknesses
Important to value other cultures
Respect being linked to an increased comfort in communication
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



Appreciating the value each team member brings (e.g. nurses, chiropodist, medical
secretary, interpreters)
Checking egos*
Hierarchy of professions and between students (grad: undergrad)
Turfism*
Note: *indicates comment repeated
As was the case with trust, it is also apparent that mutual respect is not just between the care
providers, but between the care providers and the patients. The following exchange from the
NorWest Community Health Centre focuses on a respect theme and illustrates that respect
must extend to the patient and must be reciprocal.
We owe it [quality care] to all of our patients. They are all human beings and they are not
treated that way. You treat people with respect here and they appreciate it as they should, and
the fact that they appreciate it so much speaks to how they get treated elsewhere. I have a bad
feeling in my stomach about that, because it is not right. But at least that is what we can do
here.
But having said that, we don’t take any crap. One of the things that happened, and this was
early on in the inception of NWCHC was this attitude that everyone deserves respect, well we
deserve respect too. All it took was to put a sign up in the reception area that says to behave
yourself…can’t be flipping out. Once people realized that respect is reciprocal, it will happen.
Hierarchy was also tied into the mutual respect theme as the following two quotes illustrate. The
first is from a university instructor whose success story related to the interprofessional group of
faculty members who developed one of Lakehead University’s first IPE courses.
Another one [barrier] I would say would be hierarchy; sort of people seeing themselves as
perhaps greater contributors, more valuable, having more of the knowledge that is involved in
something called health. That, I don’t think, is everyone and I revert back to the committee [that
developed the IPE course] in that everyone’s area was valued and that was a wonderful
experience partially because of that. But I think there is a great deal more work that has to be
done for IPC and IPE to try and deal with social values that are put on certain professions in
which society or even the people within those professions see themselves as either higher or
lower on a totem pole of knowledge that can contribute to the overall area of health.
Perhaps some of the hierarchy present in our health system is eroding as evidenced in the
following observation:
I find that sometimes these physicians will walk in and some will want to be called by their first
name. Many new grads want to be called by their first name and it even takes us back a little bit.
We kind of go “oh seriously? You want to be called by your first name?” but I think even that
little bit of a gesture kind of heightens the interprofessionalism as it takes them down from the
hierarchy as this is my role on the team and it equals things out a little bit and I see that. People
are starting to gravitate towards accepting of interprofessionals.
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D. Communication
Good communication is obviously facilitated by the other interpersonal relationship themes and
by an organizational structure with built in communication mechanisms. This section will focus
on the importance of communication skills while the enabling communication mechanisms will
be discussed later as a condition within organizations. Excellent communication skills are one of
the key elements of team work. One participant summed it up this way:
When I think about the teams I’ve sat on that have been highly collaborative, it has been around
knowledge of roles, it has been around process issues and understanding the expectations,
having excellent communication skills, and having the time and space to collaborate.
Communication amongst all the players directly impacts patient care as illustrated by this quote:
…[patients] behave differently for a lot of different reasons and the more feedback that you can
get about the possible reasons a person may be reacting or behaving in a certain way, the
better. And to always include the person to who we are committing our goodness upon; the
client, the patient, the consumer or whatever we are calling them these days, to make sure that
they completely understand, or whoever their caregiver is to understand what is going on
because there are a lot of unintended consequences of one discipline or somebody moving
ahead in one direction and everyone is not quite sure or they don’t feel assured enough to say
something.
When language barriers are added to the mix, the recipe for unintended consequences can
become more potent. The Sioux Lookout Meno-Ya-Win Health Centre has employed
interpreters and they have proven to be invaluable members of the care team in that setting.
Even with access to an interpreter, there are unmet needs as it should be noted that in the
Sioux Lookout area there are 19 First Nation dialects and three distinct languages. The
importance of an interpreter was noted in the following story:
They are a very important part of our team. Many patients are down here by themselves. They
don’t pay for family members to come. They don’t speak our language and I don’t speak theirs
so there is a communication problem and without the interpreters we would miss a lot. They will
also visit with the patient and from a Nursing standpoint I am able to treat my patients so much
better because of the interpreter, because we can really discuss things with the patient through
the interpreter and have a dialogue. Without them the dialogue isn’t there….. I take patients to
Thunder Bay for CT scans …., but there are no interpreters and I’ll never forget; I took a
gentleman down there and he had cancer and he was going to go see the chemo specialist as
his cancer had come back. There was no interpreter. It still haunts me are talking about this
man’s life and there was no way he could make an informed decision about what was going on
and I knew the gentleman didn’t understand.
An observation from the various focus group interviews was that good communication skills and
positive interpersonal relationships were evident within the interviews themselves. Because the
focus groups were purposively recruited from settings where expertise and positive inclination
towards interprofessional care (IPC) or interprofessional education (IPE) would likely flourish,
this finding was not unexpected. It is something though that is not picked up from examination of
the transcripts alone. One could easily see that the positive body language and tone, the good
natured joking, and the respectful and attentive listening that were apparent during the
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interviews would also lend themselves well to collaborative patient centred practice. They enjoy
working together.
Conditions within the organization
All of the interpersonal relationships that guide collaborative patient centred practice are
impacted (either positively or negatively) by conditions within the organization. These conditions
can be categorized as dealing with the organization’s philosophy, administrative support
(including leadership), team resources, coordination/communication mechanisms, and
organizational structure.
A. Organization’s philosophy
An organization’s philosophy guides policies, vision, mission, roles, responsibilities, goals and
interpersonal relationships. Elements of an organization’s philosophy can be spelled out in
vision and mission statements, the leadership in the organization can greatly influence the
collective philosophy and finally the day to day interactions of all of the people within the
organization reflect organizational philosophy. The following descriptors were often associated
with the organization’s philosophy in this survey:
Common Organizational Philosophy Themes
Patient Centered descriptors
 Responsive to patient’s needs
 Caring
 Flexible to the life experience of the patients
 Empower clients
Prevention descriptors
 Prefer “client” over “patient” (patients are ill)
 Holistic
 Prefer broad definition of health, to include lifestyle
 Wellness model instead of illness model (proactive not reactive)
 Preventive vs. reactive
 Focus on children’s health
Collaborative descriptors
 Celebrate uniqueness and value of each profession
 One team
 We are all in this together
 “Allied” as in “allied health professional” is a misnomer if all professions are equal
Value continuing education
 Pro-academia
To some degree, individuals in all of the IPC settings interviewed made comments that implied it
was their organizational philosophy to support preventative patient centred collaborative care
and further they highly valued continuing education opportunities. Similar to the individual’s
“willingness to collaborate” it would appear that for the most part there is an organizational will
to collaborate as well. One difference between organizations may be the extent to which other
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conditions within the organization allow this to happen. It would also appear that if IPC is to be
promoted, organizations will want to leverage their organization’s philosophy to make some of
the implied philosophy more explicit, allocate resources with philosophic priorities in mind, and
advocate for system wide changes to support their organization’s philosophy.
While being patient centred and collaborative were obvious organizational philosophy themes, it
was interesting to note that health promotion and valuing continuing education were also
prominent discussion points with most of the focus groups. The partners in the Take Heart
Coalition and the University IP educators from Schools of Kinesiology and Outdoor Recreation,
Parks and Tourism are not front-line care providers and they have a health promotion and
health education mandate instead. Not surprisingly, these groups made the case that there
should be organizational and system changes to nurture a wellness model instead of an illness
model. Some of these related comments can be found in the “Wish list: possible
recommendations” section, but as a start one could consider the definition of IPC. Note that the
HealthForceOntario definition for IPC was shared with all participants and this definition itself
generated some discussion. One educator had this to say:
I would argue too that that word patient is very very limiting and it should say client, because
often we are dealing with people that aren’t in their best of health and are wanting to improve so
“no” they are not healthy and we are just trying to keep them there, they are also not sick. They
are wanting some assistance in improving what they are doing with themselves and their body
and that is where some of the recreation, exercise and nutritional care (and it could be massage
and some of the other professions) come into play there that will improve their health……..if I
were to give feedback to HealthForceOntario, that would be something I’d say; make it broader,
make it clients so you are encouraging people who feel they could be better in terms of how
they look after themselves and their health..…. So I could put that in as a barrier. Terminology.
The fact that IPE was seen as imbedded in IPC and in organizational philosophy and further,
that educational opportunities appear to be embraced by health care workers bodes well for a
health care transformation towards IPC. The following quote was not atypical:
In our particular setting [a Family Health Team], I don’t know anyone who doesn’t wear at least
two hats [educator as well as care provider], so our setting is very pro-academia. We all host
medical students, residents, social work students, and soon to be hosting nursing and Nurse
Practitioner students. So yes, we are very much connected to the university and to the medical
school. We are all in this organization very pro-learning and pro-offering opportunities. We are
all on the same page with the importance of that.
B. Administrative support
In settings where collaborative patient centred care was flourishing there was inevitably
administrative support to facilitate successful delivery. While the administrative support could
range from administrative assistance to a leadership position (and both ends of the spectrum
were highly valued), it was generally administrative leadership that generated discussion
amongst the focus groups. The bar was set high for what individuals are looking for in
administrative leadership. Borrowing some words from various interview participants, this
individual should be a champion of IPC and/or IPE and should thus provide proactive leadership
with a vision to drive organizational philosophy. He/She would need to be courageous to take
chances, to do the right thing, to pull professions together, to create change and to engage the
First Nations. He/She would need to be creative in allocating resources, finding new solutions
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and getting around some bureaucratic bylaws. Their administrative style would of course be
collaborative. It was acknowledged in the interviews that IPC is a lot of work and therefore
support for champions (be they in administration or elsewhere) is needed. Ideally this support
would be systemic. Preparation for administrative leadership was noted in one focus group:
I think health care management leadership needs to think of taking IP practice to the
management level, because it has tended to be very sector specific still….
I am glad you are making that point on the management level; I would say that within my areas
of responsibility I am really glad not to have a homogeneous group of managers with respect to
clinical background. I have folks who are from Nursing, from Psychology, from OT. The mix is
phenomenal because they think differently. So you put people in the room together and they are
all looking at problems in a very different way, but it comes together in a very solid, problem
solving solution in the end.
The strategy of cross pollination (i.e. moving people around within an organization) to develop
leadership potential was also discussed:
I’ve brought people in from different corporations, like going back to our addiction program;
someone from the Children’s Centre Thunder Bay came here and managed our youth
programs. It helped our youth programs, it helped that individual and it helped Children’s Centre
Thunder Bay for we ended up with a nice integration of the program areas. At first it was “oh
God, OK I’ll do it” but then after it was like “what a great opportunity”. Maybe that is part of
education in the training part. You don’t want to be in a program for ever and ever so here are
opportunities.
C. Team Resources
The “wish list” section of this report testifies to the importance of team resources for both IPE
and IPC. Resources can take the form of time, human, space and financial. Compelling cases
can be made for all of these resources, with the bottom line argument being that investment in
IPE and IPC will likely improve patient care in a cost efficient manner. While each IPE and IPC
setting would have different resource allocation priorities, some generalizations are as follows:
C.1 Time
With the busy, often hectic, schedules of many health care professionals, there is sometimes
not enough time in the day to engage in IPE and/or holistic IPC. Designated time is needed for
holistic care (home visits and outreach), team meetings, IPE opportunities (like grand rounds,
student/peer mentoring, team orientation), and reflection, evaluation and dissemination. It was
felt that Nurses, who because of the sheer size of the profession, would be the key profession to
buy into IPC as this would start an “avalanche” of support. Unfortunately though, it is the Nurses
who may have the greatest time constraints in attending IP education sessions.
At St. Joe’s we always plan noon hour education sessions. Fabulous, fabulous sessions,
teleconferenced, video conferenced but you never got the nurse down there and the reason you
don’t get the nurse down there is that they are too busy up on the floor feeding the patients, and
doing things for the patients so after a while the hostility and resentment comes from the
nursing, who sees all of the other disciplines going to these things coming back all enthused
and excited and here is Cinderella upstairs on the floor doing all the work.
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Other (non-nursing) participant: we have the luxury of being able to schedule our clients.
C.2 Human
Human resource management in the health care/education sector is a major concern for NW
Ontario. To make IPC and IPE work you need the “right person for the right job”. Not only is
there a shortage of many professionals and qualified support personnel, there is also concern
with stability/sustainability of the health workforce. Human resources are linked to time or
money resources as more than one participant shared sentiments similar to:
…back to that efficiency piece is that sometimes we are just so bare bones, it is not that we are
resistant to change, but how do you back fill that direct care person to do grant proposals and
do all those things so you can do the innovation.
On the bright side, there is anecdotal evidence that IPC models, like the Family Health Teams,
Maternity Centre and Community Health Centres, are effective components of a recruitment and
retention strategy (see also care provider benefits of IPC on page 17). Workers appreciate the
team atmosphere and support and belief in the end goal. For example one staff member noted:
I’ve been here for nine plus years. What we are is an IPC centre and it is wonderful. These girls
keep me busy with all their paperwork and referrals. It is a big job, but it is very rewarding and I
like it.
Another counsellor commented:
I don’t think money is the motivator. Until you have worked in a really collaborative model, I
don’t know for myself anyways if I truly appreciated collaboration…until I was doing it all these
years. And once you have done it, and that is what I say when I look back on my career and
look to the future, I wouldn’t want to do it any other way. It is just better care; less patients falling
through the cracks.
C.3 Space
There is a lack of space to fully integrate IPE with IPC. For example there should be meeting
rooms big enough to accommodate the whole team and examining rooms large enough for
multiple learners or other care providers. When patient centredness is added to the mix the list
of space needs grows (see wish list section). Nonetheless, in the settings interviewed teams
were making do with what was available. One of the keys was simply collocation of the various
professionals so that communication, both formal and informal, was facilitated. Communication
mechanisms will be discussed later.
C.4 Financial
Financial resources have been alluded to with the other resources as a lack of any resource
often comes down to financial limitations. It is important to note though, that more often than
not, the frustrations related to financial resources had less to do with total money in the system,
but inflexibility of financial resources. Silo’d funding at the system level often means inflexible
financial resourcing at the health care organization’s level. The silos we build (due to
educational system, social system, professional system, etc.) is a cross cutting theme and will
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be noted many times throughout this paper. The success stories cited in this review are usually
examples of individuals navigating around the system. For example:
One of the reasons our health centre is doing so well is that we have found a way, like [other
participant] to bypass the system in many situations. We have found a way to bend the rules, to
twist the guidelines, to make it work for us. That takes a lot of energy. Most people won’t do that
which is why a lot of organizations are stuck in paperwork.
Payment plans can create either an incentive or disincentive for IPC. It was noted by many that
the fee for service is a barrier to IPC as it incents procedures and billable consults instead of
holistic care management. While it is beyond the scope of this environmental scan to do an
assessment of different payment plans, the patient panel (the unique, unduplicated, discrete
patient population for which the physician/team is responsible) appears to incent holistic and
population based care, while holding the team accountable, Jubber, 2009. The patient panel is
being used in Alberta and would define the work (demand) by the physician/team and would be
adjusted to account for patient characteristics (i.e. diabetes, depression, elderly, etc.).
D. Coordination and Communication Mechanisms
A large part of the resourcing in the previous section could be directed at coordination and
communication mechanisms as this could be considered the key to not only
coordination/communication amongst the health care providers, but with the
patient/client/resident, the administrative staff, colleagues in one’s own profession, the IP
educators, the community agencies and the professional and governmental bodies.
Communication mechanisms can take many forms ranging from informal hallway chats,
telephone calls, conferences, websites, print media, formal referrals, electronic medical records,
telemedicine, mentorship (of students, colleagues and patients), team meetings, etc. Essentially
all consumers or providers of health education and/or care need to be able to communicate
(meaning both sending and receiving messages) clearly and efficiently. Communication is only
successful when both the sender and the receiver understand the same information as a result
of the communication. The degree to which this is accomplished rests on the communication
skills, knowledge and attitude (covered previously) plus the mechanisms in place that can
facilitate the transfer of information. Although a communication mechanism(s) could be
identified in every IPE or IPC story, some common themes included: technology, case
conferencing, the role of the NW LHIN, program management, collocation of health
professionals, communication to the broader community, and system navigation.
D.1 Technology
Technology presents both opportunity and challenge. Technology, such as electronic health
records, telemedicine and web based instruction can make IPE and IPC more accessible,
efficient and effective. Electronic health records were praised by a Family Health Team care
provider who noted:
We are on electronic medical record, so we are all looking at the same record, we are all
sharing the same file and again sort of wrapping ourselves around the patient to provide the
best possible care…
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Telemedicine was viewed as an excellent facilitator of IPC while additionally addressing the
distance barrier as one participant recounted the story of a telemedicine mediated physical
assessment:
It was interesting to see where the orthopaedic surgeon, who really wanted to physically assess
the patient but didn’t want to put the patient through an 800 km trip, was able to appoint the
local physiotherapist and have them ask, “how does that feel and how does this feel?” so you
had a kind of consult with the physio whereas normally this patient would have gone all the way
to see the orthopaedic surgeon, but there wouldn’t have been the extensive exchange of
information, but because they had to use Telehealth and because there was distance, I think it
actually improved the interaction with the caregivers. So I think if we can use technology as an
enhancement tool to have people work together more, who knows where that can lead.
While technology, particularly when creatively applied, is opening up new worlds of opportunity,
there are some challenges. For example, although web based instruction has opened up
educational opportunities for distance learners, one IP educator noted:
It has also been challenging for me to think of ways, particularly in a completely web based
learning environment; how you are going to imbed an IP component? How do you put people
into teams and how do you make it a rich learning experience? And so it has been challenging
for me to come up with some new instructional strategies, especially in that environment.
Another information technology challenge is that sometimes collaborative partners still can’t
interface properly. The family health network in Kenora, for example, has three sites all serviced
by the same IT vendor, but it is still difficult to communicate between the three sites. It was
further pointed out that the Aboriginal Health Access Centre is not able to share files back and
forth with the rest of the system. The challenge of electronic medical records was summed up
this way by another participant:
I think too though, just in terms of the challenges of electronic medical records as a support for
IPC, when you are working across the service sector, especially with community partners, when
you are looking at the whole person requiring a continuum of care, even if you have a really
solid IP practice within the team when you see that person move through the system from acute
care to complex care or from the hospital to community, those kinds of practices tend to break
down, not by virtue of an unwillingness to work together, but because people are on different
systems; There are some that don’t have access to that record system so therefore the sharing
of that information, you have funding requirements for people to use different systems and this
is something even within the same sector and so when it comes to communication, which is
absolutely key for supporting IP practice it can become very difficult to realize. A classic
example is the split between the expectations for documentation and data with the addiction
system. It is a separate system from that in acute care…they aren’t on electronic records and
yet we have, very clearly, people moving back and forth between the two sectors and two
systems so that is when, despite the willingness, the systems themselves don’t support the
work: the funding envelopes are separate and distinct and with their requirements attached they
don’t support or facilitate IP practice.
Another communication technology frustration was expressed in passing as one participant
lamented that although extensive communication networks are vital, it is also difficult to keep up;
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I mean we try, but those kind of things [communicating with various groups], they are hard
because between 100 emails a day and all the other things we do, it is sometimes hard to focus
on everyone else, but I mean that is a communication gap.
There is a saying that “science (in this case technology) is a good servant, but a bad master”.
This sentiment probably holds true in the examples above. Another caveat to using technology
wisely was expressed by the American journalist Edward R. Murrow, “The newest computer can
merely compound, at speed, the oldest problem in the relations between human beings, and in
the end the communicator will be confronted with the old problem, of what to say and how to
say it”. Fortunately the challenge of harnessing technology to our best advantage will be taken
up, for the most part, by the younger generation as one participant observed:
The whole younger population is going to have an extreme dynamic change on ways of work
and we are just starting to see some of that in some of the young employees coming into the
workplace. I guess some people in my age group have no idea on how to handle it or how to
respond. It is interesting when you read about some of the CEOs that are in big companies that
are dynamic and making change, they have like 20 yr olds that are working beside them helping
them adjust to the changing environment and changing technology, because they don’t have the
skills or the knowledge or understanding of how that works. So I think that in my view there
should be no barriers, especially with the technology. But barriers currently exist, just because
of the way people work and the way people are trained to work and they don’t know anything
else on how to make that change.
D.2 Case Conferencing and other means to communicate with the community
There is nothing new to case conferencing as an example of IPE/IPC and in fact one of the
success stories dates back to the ‘70’s as a participant commented:
In the early days, in the 70’s, when I was working at the Health Sciences Centre in Winnipeg,
which was a teaching hospital, case conferences were being held with all the disciplines on
different patients that may be difficult. There were also presentations made over a lunch and
learn where anyone could attend and usually those sessions were capturing between 100 and
150 people that would come and listen to how the different disciplines participated in the
patients care; what worked well, what didn’t work well and lessons learned in order to advance
practice. That was just amazing to me as I was entering into health care as everyone was just
working together.
The Grand Rounds at Meno-Ya-Win Health Centre were also cited by the participants as
exemplary IPE opportunities. A problem though, and this was expressed by more than one
focus group (and can be seen in the wish lists), was that we don’t apply that case conferencing
concept outside the immediate team so that more health care and health promotion
stakeholders are at the table. In that way, there would be less patients or clients falling through
the cracks. One participant explained the idea this way:
Something just came to mind, probably not feasible but, what about a case studies conference
that dealt with strictly, and I think the LHINs could host something like this that dealt strictly with
case studies around health care issues; you know on the delivery side, on the treatment side,
on the assessment side. So if you had maybe half a dozen case studies at a case conference
and you invited health care workers from all levels to come and sit on focus groups or problem
solving teams and come up with ways and strategies to handle these particular cases which are
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actual or actually reflect events that happened in the community, like these actually happened
say in the past year and that would bring professionals together and cause them to think
together, to develop some kind of approach to that particular case and that could be on record,
it could be retained and distributed to everyone present and back to their own organizations.
If not case conferencing, participants expressed the need for other ways and means of sharing
what works and what doesn’t work. It was pointed out in success stories, but more often in
unmet challenges that communication to, with and between the broader community is a key to
IPC. One health professional noted that:
I think what we don’t do is we don’t share our successes. I think there is a wish at the LHINs
level to do this and maybe you will find it with your interview and so on; it would be nice to have
some collective wisdom instead of independent successes. We are trying to link up with the
Atikokan Family Health Team, for instance, and I was impressed with how good they have
done, but how isolated they are from us, they are only 1.5 hrs from here, from the other
successes that have gone on: for example linking up with service provision, video conferencing,
telemedicine and so on, which they have, but …it would be nice to be able to share the lessons
learned idea. This is what we have done to make it work. These are the themes we have used
to drive our services.
D.3 Communication role of the NW LHIN
The comment above is probably a good segue into other communication roles the NW LHIN
could take on. The NW LHIN was thanked for the communication and engagement efforts that
they have led or facilitated. The words “led” and “facilitated” are two different roles. The LHIN
may have a role in prioritizing what information is the most important and when an identified
strategy needs to be disseminated the LHIN could lead the dissemination effort. One participant,
who was obviously a convert to IPC and the efforts of HealthForceOntario, commented:
If you were involved with the university or if you have got your pulse on what’s going on, then
when this whole HealthForce thing came on people would have read the report and they would
have had an idea of what was going on. Not everybody has an idea of what is going on. They
are so inundated with everything else. It needs to almost be a direction from the LHIN, it needs
to a regional strategy, it needs to be something that is in everyone’s face so that they have to
learn, they have to go out and read about IPE and before you know it, they look around and it is
happening all around them.
Another participant added that other LHIN communication roles could be a resource for
information and listening to concerns:
I think that the LHIN absolutely has a role in helping to move this [IPC] forward through funding
arrangements and agreements, contracts with organizations that are providing the care. I think
they have an instrumental role in saying that this is something that needs to happen. I’ve had
some really wonderful experiences with the LHIN, like amazing experiences where if I had a
concern as a health care provider or a citizen, I can just email the LHIN and I feel that I actually
have a voice, so I think it is just really important to listen to what clients and consumers are
saying and being able to move in that direction
The listening role was emphasized by the Kenora and Sioux Lookout focus groups:
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So really at a government level what I would like to see is more of you coming out to see us or
people or more bureaucrats coming out to the different towns and having personal contact with
each of the towns, rather than saying, we’ll go on the internet and see what is going on and take
all your direction from the internet. It is so impersonal and it is not very helpful. We need people
at the LHIN and at the MOHLTC level that are going back to wherever they need to go to get
resources out to our area and say here is what is going on in each of those communities.
Similarly, the need to further cultivate the working relationships with First Nation Peoples was
stressed:
I would also like to continue working with the LHINs in developing their working relationship with
the First Nations in the communities. You have to somehow do away with the jurisdictional
barrier that most of the First Nations are under Federal jurisdiction because it is the Nursing
Stations that are their primary access to health care. That is it. Some of them only have clinics.
D.4 Program management
The value, in terms of collaborative patient centred care, of moving from a department structure
to a program structure was praised at both St. Joseph’s Care Group and Thunder Bay Regional
Health Sciences Centre:
…this structure of program management, and I know I am going back a while, but I think what
you said this is the foundation of it… we were a department in a department structure, a
physiotherapy department in a department structure. You were hired to be the manager of the
department and in the late 1990s, just over a decade ago, we shifted to a program management
structure. I mean we did topsy turvy here…we shifted everything around and in essence
eliminated the psych department, the Nursing department, all of that gone into programs. And
our reason for doing it, and there were other models in the healthcare industry, was to focus on
the people that we serve and to surround the client(s) and their families with the care providers.
Everything was to focus on the client…..
Now in the beginning there were still folks who said they wanted to go back to the department
structure because that is where my colleagues are and that is where I get that connectedness.
We resisted that, because that would mean we were structured around providers and not
structured around the people that we serve. We did set up an alternate structure, or professional
practice structure where the occupational therapist, physiotherapist and the Nursing group
would get together to deal with common issues and development, but really our structure was
meant to focus on the client.
Another participant commented that the model of program management has been effective in
getting professionals working together as a team as opposed to working in their departmental
silos. We will see in the Education section of this report that courses can be restructured in the
same way. Instead of courses following a disciplinary focus, they can be structured around the
type of care provided (e.g. palliative) and students from multiple programs would use their
disciplinary knowledge to work through case based learning scenarios as a team.
D.5 Collocation of health professionals
The need to have adequate space for health care professionals to physically work together was
noted previously. There are benefits to both the provider and the client as this description of the
Fort William Family Health Team indicates:
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I could not go back to … not having the collaborative team around me simply because I think
patients or clients get missed in that way of doing things. So the service here includes family
physicians, SW, psychiatrists, dietician, RNs, NP and again we are all under one roof, we are all
housed here to provide collaborative care so yeah it is just a great experience for the patients.
This benefit and the need to design buildings with IPE and IPC in mind were reiterated in
discussion with the St. Joseph’s Care Group:
If you are able you should take a tour of our new building in Victoriaville as it was an opportunity
to move people out of the offices they inhabited, where may have previously had a whole line of
psychologists, a whole line of social workers and the occupational therapists had offices
together. So when we built the new building we put people in close proximity to their team as
opposed to their discipline. I think as an example, when our interdisciplinary teams bring
somebody into the program they do team interviews so they have one or two people actually
talking to the person and the rest of the team is behind a one-way mirror and can feed questions
back and forth if they are not hitting on everything and that way the person doesn’t face the
same question six different times.. you know where do you live and what kind of house is it,
what is your income like. Everyone feels an obligation because of their training within their
discipline to ask all those questions over and over again. I really do like that model.
In addition to facilitating formal communication, collocation (and strategically placed water
coolers) can nurture valuable informal conversations:
…after program management people were still making those adjustments and saying OK now
we are a team and so working across teams seemed challenging or difficult, but what was
fascinating about the process was that all it took was setting up water coolers (this was about
eight years ago) and that was it. Strategically placed water coolers in the building facilitated the
conversations and people that weren’t talking to each other, all of a sudden were talking and the
need for formal referral just drifted out of sight because people were client focused…it was their
value, it was what they wanted to do and so without doing any kind of formal anything, the
barriers just gave way by virtue of professional practice
\The collocation also speeds up the flow of information:
Generally speaking I think that the flow of information happens a lot quicker here in this service
setting and it works really well between us professionals and our patients or clients. It is just a
lot easier to walk down the hall and say “hey check this out” or “you know that is how I would
say it”. Yeah it just works really well. People are getting care faster, quicker and more efficiently.
D.6 Navigation through the health system
One of the purported benefits of IPC is greater access and shorter wait times for patients and
clients. This can only happen if there are good navigation mechanisms. The story below
illustrates how an IPC team (shared mental health) can surround and support a patient as the
patient navigates the health care system (and also how IPE can be woven into IPC).
…I would use an example of a pregnant woman who sees a family physician and finds out she
is pregnant. She may be on a medication for mental illness such as depression and she may or
may not have seen the counselor and I may have been involved only on a discussion basis on
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what is the right medication before the choice was made. Not having to see the patient [is
efficient] but the patient didn’t have to be referred [and thus wait] to get an opinion on “Gee I’ve
tried two others, what should I use?” […] that opportunity to be involved indirectly [also allows
the patient to] not be stigmatized by the formal process of five or three years ago of going to the
LPH [Lakehead Psychiatric Hospital] for an assessment on what to do after two medications. So
[it is an advantage] being able to be engaged at that level. That patient may have been
connected with a counselor either here at the outpatient area or at one of the primary care sites
and may have developed a relationship with that counselor and I may, on a second time, been
able to engage with the social worker, a psychology perspective on this same individual. Once
she finds out she is pregnant, let’s say a year or two later, then the issue of her pregnancy, the
right medication, and some more medical issues return into the picture. [This presents] an
opportunity to discuss with the family physician the use of, for example, the Mother Risk website
in getting information on what is safe in pregnancy. Since this is up to date information it forces
me to learn more and review what information is available. So it is a challenge for me at an
intellectual/educational level. That [can then] lead to a discussion with all the family physicians
about what I have learned here and use that as a case example for me and the family physician
talking about that with other physicians and possibly summarizing the counsellor’s experience
as we implement the correct medication and adjust. […] To me that allows, at the end of the
day, only efficient documentation and only efficient communication.
The patient centred aspect of the above story is the key to navigation. One needs to identify the
navigation barriers as seen through the eyes of the patient/client in order to devise ways to go
around or through those barriers. Here are just a few navigation tips mentioned in the
interviews:
We [shared mental health] are funneling all the referrals through the family physician and we are
doing that very purposefully based on the numbers. Because the numbers that they send down
to us are such that we are very very busy. I’ve never worked in an environment where I have
carried this size of case load that I carry here. None of us really have, so we really like the
physician to be the gate keeper to the system on site in order to make sure that the people who
need the service most are receiving it and again the collaborative nature of the service is not
meant for people to just attend separate from the family doc. It is meant for us all to be working
together as a team.
With some patients, ensuring there is someone who gets them to their appointments or even
attends appointments is vital:
And this was an individual who had very high risk social life/situation. She was developmentally
delayed. There were concerns around behaviour, lifestyle and potential for violence. Anyway the
long and short of it is that we worked with this girl and partnered with her care provider in the
community who was a real support to her and attended all the appointments with her and there
was a lot of time that needed to be made available for her delivery, because it was going to end
up in a child welfare apprehension.
If they don’t show up [a Nurse Practitioner] is the one who finds them and gets them to their
appointments. Understand that they are new to the city, don’t know the ways to use the health
system (used to going to the Nursing station), kids are facing a lot of racism and trauma,
problems with drugs and alcohol (some have almost died from alcohol poisoning). We work
closely with [community partners] to ensure follow up and get referred to counseling.
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The medical secretary can be an integral player in navigating the system:
The role of [the] medical secretary is essential: Vital in getting things done. Collaboration with
administrative staff is essential and can’t be overlooked.
Because not everyone knows the specialist, she makes friends with the specialists’ secretary,
so she can get past the little barriers.
Not only can she get through to the specialist receptionist, but she has the magical skill of
getting clients appointments sooner. Receptionists know that if we [a health care organization]
say it is important, it is important to get a patient in quickly.
Outreach, and integration with community agencies, is a way of bringing care to the people,
thus possibly avoiding a healthcare navigation journey starting at the emergency department:
Another example [of a success story] is the outbreak of invasive group A Strep in Thunder Bay
(leads to flesh eating disease). [We] got very involved in the community with this. We started
seeing more and more people walking into the clinic here and at Shelter House, many with
wounds that they weren’t following up. [They] might go to emerg and wait eight hours and then
leave. We were able to do the outreach from Shelter House and we were able to bring them in
and hand out the antibiotics, get them to start taking them right away. We saved lives that way.
People didn’t have to go to emerg and we were able to get their infections cleared up.
While all these tips may be helpful, it was common to hear navigation of the health system as
being a barrier. The particulars as to why it is a barrier were varied and ranged from
transportation, access and knowledge of what resources and agencies are available.
E. Organizational structure
Note: Organizational structure relates to many of the previously covered themes; organizational
hierarchy, collocation of health professionals, resource issues, and program management.
Organizational structure is either a reflection of these various themes, or these various themes
are a reflection of organizational structure. A different author could quite justifiably reorganize
which topics fall under which heading.
Wikepedia defines an organizational structure as a mostly hierarchical concept of subordination
of entities that collaborate and contribute to serve one common aim. It goes on to note that
common success criteria are:

Decentralized reporting

Flat hierarchy

High transient speed

High transparency

Low residual mass

Permanent monitoring
Each of the settings interviewed would have a different organizational structure as their aim is
different. (See the description of focus group settings in appendix A). For example this excerpt
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makes the distinction between the NorWest Community Health Centre and a Family Health
Team.
The fact of the matter is that our patients do not have a voice. If NWCHC wasn’t here, they
wouldn’t get the care and they would not complain about it, they would end up just going to
walk-ins and emerg, they would end up with more serious problems down the road that would
end up costing the system more money, they would not have any access. The only way to
provide care to the patients we serve is by doing this collaborative care and by doing it in the
way that it is done here (real collaboration with people that get along and with an administrative
staff who know how to run things).
Elements of the success criteria noted above could be seen in all of the focus group settings.
Some observations include:

Decentralized reporting: The Provincial move to Local Health Integration Networks
would be seen as a positive step towards decentralized reporting. The benefit of this is
that it was thought, people living locally were better able to plan, fund and integrate
health services in their own communities than people in Toronto. Sentiments expressed
from the some organizations would indicate that they would like to see that logic
extended even lower on the organizational structure so that the uniqueness of individual
health care settings could be acknowledged in accountability measures.

Flat Hierarchy: Within many organizations it was apparent that there was a fairly flat
hierarchy. No role was seen as being of greater or lesser importance, but instead words
and actions reflected mutual respect amongst the care providers, administrative staff
and patients (see section on mutual respect).

High transient speed: The close connection health provider organizations have with the
community, the open communication channels care providers maintain with each other
and the expedited referral system that is facilitated by a medical secretary all allow the
organization to respond quickly to health concerns. The final two stories in the
Navigation through the system section illustrate these points.

High transparency: One could infer that there was a high degree of transparency (i.e.
in collaborative decision making) from the open, honest and direct dialogue that took
place during many of the interviews. Communication skills combined with
communication mechanisms also set the stage for high transparency.

Low residual mass: In other words everyone is pulling their weight. A truly informed
comment is probably beyond the scope of this scan, but there certainly was ample
evidence of many team members doing work above and beyond minimum requirements.
As noted below this is because the staff care for their clients.
The absolutely most critical piece in terms of our success has to do with relationships and we
have to have compassion for our clients and I can genuinely say that our staff care for their
clients; they care about what they do.

Permanent monitoring: Successful organizations emphasized the need to make the
reporting efficient and relevant to ensure quality care.
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E.1. Silos
In all focus groups the challenge of breaking down silos in order to promote IPE and IPC was
mentioned. Silos are a part of the professional systems, educational systems, government
bureaucracies, funding agencies, community services and geographical jurisdictions. The whole
essence of IPE and IPC is to break down, if possible, some of the silos. There were a number of
success stories related to breaking down silos.
The Thunder Bay Regional Health Sciences Centre (TBRHSC) has collaborated with St.
Joseph’s Care Group in resource sharing:
We share staff and in the area of rehab the staff that work at TBRHSC are St. Joe’s staff and
that is our area of expertise and we have staff from TBRHSC that we buy their services in the
areas of lab and x-ray services and a variety of others, so there is the sharing between the two
facilities. The staff work for the facility that is mandated to provide that type of care. This is also
going on in the area of mental health so we are expanding.
The Family Health Team in Kenora has also overcome some jurisdictional silos in their
collaborative arrangements with Winnipeg. So there definitely are success stories, but many
challenges remain:
…one more feature that makes us unique and that is our distance to Winnipeg as opposed to
any other Family Health Team. Their physical location makes them closer to Thunder Bay. Our
direct link to advanced services like cancer care and other emergency services and specialist is
to go to Manitoba so across the border, which perhaps makes us unique from any other Family
Health Team in Ontario. We have a very good, I think in many cases, good working relationship
and reciprocating care with Winnipeg which other Family Health Teams probably don’t have or
don’t have that connection.
…everywhere else in Northwestern Ontario everything is set up to go to Thunder Bay. Well that
is a major inconvenience for people in Kenora to have to go to Thunder Bay. For example, for
breast cancer care many people do go to Thunder Bay for their radiation treatments and that
can be devastating family wise and financially, whereas if the reciprocating facility is in
Winnipeg, that trip can be done in a day. So being patient centred (who is the most important)
[we should] have them go to Winnipeg within a day.
The Kenora group also identified, and were thus able to address, community service silos:
When we were doing our initial program development one thing that we did was [two health
professionals on the team] went out to the community to see what is being delivered right now,
what is there, what the priorities were, what the gaps were and what we discovered was we
have lots of services, […], one thing we struggle with as a community is that we are not very
coordinated in delivering those services and I think it is most unfortunate. Diabetes is a classic
example and our physicians can tell you that yes there are lots of services, but they don’t really
know what is going on with their patients and for whatever reason our community has not been
collaborative, it has not been partnering and we need to work very hard on that and we are not
very integrated.
In a few focus groups unions were regarded as a challenge to breaking down silos..
Different salaries, with different funding bodies with different union groups shouldn’t be those
structures that get in the way of good care.
Because of their unique mandate of addressing both interprofessional and interorganizational
silos, the participants in the Geriatric Interprofessional Interorganizational Collaborative (GIIC)
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were asked which boundaries (interorganizational or interprofessional) were the tougher to
break down.
I’ve seen the interorganizational piece be the biggest challenge, if I have to pick between the
two. … It is the accessibility, it is the lack of resources, it is the transportation. We could be
sitting around the table, whether it was in the north west or in the north east and we talk about
how great it is to have these exercise programs for depression and being able to motivate these
seniors and we have these great discussions and it always stops at the same block; we can’t
get the people there or they aren’t able to participate or we don’t have such a program there or
nobody can run one at the rec centre or the 55 plus.
The GIIC participants, while noting that interorganizational barriers are daunting, also
commented that Northwestern Ontario actually overcomes many of these barriers out of
necessity. They speculated that people in the North have developed tight networks because
there are few resources and thus more dependency on each other’s organizations.
As was noted in the discussion on technology, there may be reason to believe the younger
generation could lead the way in breaking down some silos.
This generation we have coming up, they aren’t so good with these hard structures, you know
they are a little more into flex and fluidity than maybe our generation and they are more
comfortable with the technology and won’t tolerate, you know we tended to reproduce our
structures in the technology, and so I think there are some encouraging things to come in terms
of that generation, I think unions have certainly provided some good functional role and have
been a helpful thing, but I think their time will pass, because I don’t think this generation is going
to be as comfortable with that kind of containment.
Systemic determinants
Four broadly defined systems (educational, cultural, professional and social) make up the outer
ring of determinants of collaborative patient centred practice.
A. Educational system
The educational system obviously has a huge impact on IPE and IPC (IPE and IPC are
inextricably linked). D’Amour and Oandasan’s, 2004 model of IPE and IPC can serve as a
companion to the model used in this paper to show the interface between the educational
system and the care setting. The former basically being a deliverer of IP competencies to the
latter. Although the context is different (educational institute versus care setting) the same
themes or determinants that apply to a health professional team also apply to a team of
educators designing a learner centred IP curriculum (for example, willingness to collaborate is
central). Proponents of IPC see the need to make IPE and IPC even more inextricably linked
(i.e. practice settings need to be more integrated into education settings and vice versa).
Moreover care providers (with patients themselves being part of the care team) should
simultaneously be taking an explicit teaching and learning role, so there is a culture of teaching,
learning and researching in care settings. One can’t escape an implicit teaching and learning
role as, for better or worse, modeling is perhaps the most powerful mode of teaching. One
participant explained:
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I was part of a teaching and ethics curriculum for a number of years … and over and over again
it was just really clear that we can talk about some of these ethical principles, how you reflect on
ethical issues and how you can integrate it with your practice as health providers, but as
learners if you are not working with people that are modeling that, that are at least modeling
their aspirations to be an integrated practitioner, it is very hard and so similarly if we are not in
an organization where there are clearly people that are part of the organization that are
modeling an interprofessional way of doing things, it is very tough. Because people will see
people saying do as I say not as I do. I think those are challenges.
One of the major gaps of the education system relates to this lack of integration between the
university and the worksite:
And that [IPE at the University] is where it starts and so what I am immediately worried about is
those poor souls [the students]. They are expecting an interprofessional environment and so
how do we do the bridging as they may find the direct care providers are not all caught up with
this. The education of our direct care providers was not at all based on any of these principles
So [two IPE instructors], you can do all these things with the students in an academic setting,
but wham we will knock it out of them, I tell you, when they get here, because they are not going
to see that [IP] environment necessarily so.
Topics raised around the education system could be linked to who should be taking IPE, who
should be delivering IPE, what they should be learning (competencies), and how they should be
learning it:
Comments about Interprofessional Education
Who should be taking IPE
 Recruit right students into health professions (want to be there for health and not other
reasons)
 Medical training for interpreters would enhance their contributions
 Train personal support workers (PSWs) since small communities lack health
professionals, but PSWs could continue treatment plans
 Managers in health care need IPE training (or else it won’t happen)
 Nursing is key (largest workforce and curriculum needs adjustments)
 Faculty teaching IPE first need to learn with, from and about each other
 When you work in IPC you learn from each other and you learn by collaborating
 Medical students need to be included more (medicine often viewed as leader of health
care)
 For sustainability need to enhance IP skills of providers in community
Who should be delivering IPE
 Definite University role at the undergrad, grad and post grad levels in all health sciences
 Every single [health science] course at undergrad level should have IPE component
 Role for LHINs to share IPE/IPC success stories, identify gaps
 Trust/confide in other professions allows learners to get their training from others
 In-service learning key
 [our health centre] is always open to taking on students
 Use student teams to inform clinical teams
 Champions needed (in both academic and care settings)
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

Need a coordinator of placements
Clients are educating the community (as to benefits of IPC)
What should they be learning
 Continuing to increase knowledge and trust
 Skills in interdisciplinary or outside the box decision making; tolerance for diversity
 Learning together will drive IP culture
 First hand cross cultural training is needed (especially in Northern Ont). NOSM students
will have better appreciation due to placements
 Leadership competencies specific to IPC setting
 Don’t realize what you don’t know about another discipline until you sit down and they
tell you what, how and why they do it that way
 Courses where students recognize difference between multiprofessional and IP,
communication skills
 That IPE is an approach, rather than actual content
 Need to understand what other professions do
 Need to give high priority to IP knowledge and skills
How should they be learning it
 Continuing education (e.g. case conferencing)
 Students should take a rotation up north
 Move people around to cross pollinate knowledge, skills and attitudes
 Web based learning environment (helps logistics and distance, but challenge to make it
a rich learning environment)
 Have diverse faculty in one program
 Apply lessons from one context (e.g. ER) to another
 Facilitating Leadership in Interprofessional Care (FLIC) project helpful
 IP placements
 Need to experience and reflect on IPC to understand it*
 Need for loud and consistent IPE
 Celebrate success stories in IPE and IPC
 Patients (or target population) need to be consulted
Note: *indicates number of times comment repeated
At the risk of oversimplifying much of the information above, some general statements could be:




Everyone learning, practicing or managing in the health sector needs ongoing IPE.
Responsibility for IPE is shared across post secondary institutions in partnership with
health care institutions, the LHINs and community agencies.
IPE/IPC competencies should encompass cross cultural training, leadership
competencies, communication and interdisciplinary decision making skills.
All partners should use the tools at their disposal to enhance IPE, with experiential
learning being key.
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B. Cultural system
Culture was mentioned in two contexts: The need to develop a culture of patient centred
collaborative care and the need to be sensitive to the culture of our constituents (often remote,
rural and Aboriginal).
B.1 Culture of patient centred collaborative care
Although the participants in this study were all proponents of patient centred collaborative care,
one could argue that the prevailing set of shared attitudes, values, goals and practices has not
yet embraced this model of care. What is being proposed then is a cultural shift so that IPC
becomes the norm.
Culture change is something that doesn’t come very quickly obviously. I would say the people
you see around this table is a minority and not the majority, but you have a sufficient amount of
health care providers who are interested in collaborative care and you have much more of the
population that are seeking it. I don’t think this small group can saturate the demand of the
population who actually would like this kind of care and asks for this kind of care. That is a bit of
barrier plus wish list. I wish it would happen. The barrier is so multifaceted it is sometimes hard
to pinpoint it. The culture change I guess can be summed up that if there is a will there is a way
and that goes for the care provider, that goes for the decision makers, that goes for the
politicians and the Ministries.
One of the limitations of this study was that only proponents of IPE and IPC were interviewed.
Prior to implementing a strategy for IPE and IPC there should be an opportunity to give voice to
groups and individuals who may be reluctant to a shift towards collaborative care. Airing any
concerns will either decrease the perceived threat or in fact modify whatever is being proposed
to mutual benefit. One participant expressed these thoughts this way:
…the challenges with those particular programs was also giving credit to the culture that existed
before and so I know that [XXX] worked diligently to address those issues around the
divestment piece and what that does to people in terms of feeling valued and feeling recognized
and feeling appreciated. So I think we also need to take a look at those broader influences and
it is not just in the workplace, I mean this is a stressful life that we live and people’s lives are
under tremendous stress and you know the economy in the area, employment and families kind
of breaking down because folks are leaving to get work. I mean there are so many challenges
that we see that people do bring those pieces of their life to the workplace by virtue of the fact
they are human beings, so I think we also need to take a look at those issues that will help
enhance self esteem, help people deal with the stressors of life, so that the workplace feels like
a place where they are recognized and valued, where they are seen as doing a good job…that
whole strength based model in terms of managing situations so they don’t see IPC as a means
of scrutiny or looking over their shoulder or somebody else criticizing their work. I think it is a
huge piece in why sometimes this breaks down and people are reluctant to move forward.
It was previously mentioned in the sections on technology and organizational structure that the
younger generation may be the ones more apt to embrace those aspects of IPC (although one
participant thought strong advocates can also be found amongst experienced practitioners who
have better basis for comparison; see willingness to collaborate section). If willingness to do
referrals to other health professionals is a characteristic of an IPC culture shift, then a focus on
the younger learners appears to be paying dividends:
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I just wanted to say along that line, you started early just learning about that culture of
collaboration, one of the things that they have done here, is that they are educating medical
students and residents and boy has that had an impact far beyond what I thought, because now
these medical students, and you guys might speak better to it, by learning early as opposed to
maybe getting jaded later on from people who had been in the funding system for a little longer,
they are referring more. [XXX] can you speak to that more?
[XXX]: Well they are referring period.
B.2 Culture of constituents
A sensitivity to the culture of one’s patients is wrapped up in those core ingredients of
collaborative patient centred care of trust, mutual respect and communication. Some of the
participants had been involved in cross cultural training and it appeared to be well received and
applicable to their work:
I just like education in general because there is so much we don’t know and going to this [cross
cultural training] it has open my eyes so much and I started to look at things differently. For
example, there are three [cultures] for the Aboriginals and they all have their own traditions and
ways of doing things and we should be open to that. But then it is not just our aboriginal
population; we have a lot of Italians, we actually have Lebanese up here.
Food is part of one’s culture and the importance (beyond just the cultural sensitivity) and
struggles to serve traditional Aboriginal foods were discussed by a couple of the focus groups:
When you look at the social services there are many, many patients who find it very difficult to
survive when they come out of their circle of certainty, their safety parameters and they find it
very strange to come to a hospital and they find it very strange to eat different foods. Like the
other day she [a nurse] came running up to us and she said you guys get us some traditional
foods, my patients are having the runs. ….
They come in from the north and they don’t eat pasta and we shove it down them and then they
all get the runs…we are just making them sick.
In addition to cross cultural training and allowing traditional foods to be served it was noted that
the interpreters (Sioux Lookout) and Native liaison worker (Maternity Centre) are important for
cultural support.
C. Professional System
The major theme that related to the professional system was that of silos and turfism.
Professional bodies, by setting accreditation standards and scopes of practice, directly impact
the education and practice of health professionals. Professionalization has historically run
counter to the development of IPC as it has placed higher priority on autonomy and control than
collegiality. This may point to a root cause (but also a strategic remedy) of professional turfism.
Some participants felt the regulatory Colleges were still not supporting IPC (or at least some of
the wording could be interpreted as not supporting IPC).
And it [IPC] is still not supported from a College regulatory perspective. The regulatory Colleges
in terms of how they lay out standard practice guidelines which is their job say that “you shall
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take a history and you will do this and do that”, so doing it in this kind of model, a lot of people
who want to be more resistant can fall back on their College Standards say “I have to do this”
and so we are caught between this as an organization those College standards and how literally
people want to interpret them, and sometimes if it suits them to interpret them really literally,
they do.
Nurse Practitioners are filling a care void, particularly in Northern Ontario, but clarity of their role
and resistance from the Ontario Medical Association may be two barriers to them becoming well
integrated into care teams.
For me some of the other challenges are not necessarily in this model of care but there are
differences between Nurse Practitioner and differences between physicians… sometimes the
roles are not clear in this type of care.
Another participant cited the regulatory bodies as resistant to change and thus a barrier to IPC:
You have some resistance to changing or expanded roles. One example would be OMA’s
[Ontario Medical Association] resistance to Nurse Practitioners in having them more involved in
the provision of care. They were not supportive and resistant to change. And there is resistance
to the changing scope of practice for RPNs [Registered Practical Nurses] and some resistance
from the RNs [Registered Nurses] and so as long as that continues that becomes an
impediment and a barrier to making change, and I think change for the good... getting more
people involved and working at a different level.
D. Social system
The social factors that were mentioned during the interviews were power differences (hierarchy)
between different professionals and the social status that makes up the clientele in some health
centres. Hierarchy plays into IPC in that it is reflected in the core ingredient of mutual respect.
Specific examples were previously noted in that section.
The other social factor was brought to light during discussion with the NorWest Community
Health Centre. Understanding the problems of marginalized people is obviously integral to
patient centred care, and the NorWest Community Health Centre understands that well.
Unfortunately society in general may not share this understanding (perhaps because
marginalized people don’t have as much of a voice).
I wish that society would understand the problems that marginalized people have, the suffering
that they have and that one human is equal to one human and they are human beings that
require caring and services. Wish everyone could understand what our staff understands, so
then we wouldn’t have to justify our existence…then our people would be OK because we would
get more services and all that other stuff would happen.
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8.0 Recommendations: Wish list summary
Question #3 asked “What and how could progress be made in regards to IP care?” and
continued with the solicitation of a wish list participants had for IPE and IPC. While these wishes
have been incorporated into the previous model, the following four wishes reflect a synthesis of
the major wishes. A compilation of all of the participant’s wishes follows in appendix B.
Education: That IPE be embraced in education, care and community support settings (because
IPE competencies clearly enhance quality of care). In educational institutions this could be
evidenced by all courses for all health professions having an IP component, often using type of
care as a theme (as opposed to discipline), while in care settings there is more in-service IP
learning.
NW LHIN: That the NW LHIN incent IPC through funding arrangements while recognizing the
unique challenges of working with marginalized populations.
Integration: That silos, be they academic discipline, professional, sector, community agency,
union or government jurisdiction be dismantled through integration and improved
coordination/communication mechanisms.
Wellness: That the present illness paradigm be replaced with a wellness (i.e. prevention/health
promotion) paradigm.
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Appendix A: Description of Focus Group Setting
The following descriptions were pulled from the respective websites of the focus groups.
Anishnawbe Mushkiki Community Health Centre:

Anishnawbe Mushkiki is an Aboriginal Community Health Centre which has been
established as a primary health care facility within the District of Thunder Bay.

The Centre's mandate is to improve the health of Aboriginal people by means of a
wholistic approach combining western traditional and alternative medicine.

Programs and services are provided to Aboriginal individuals, families and communities.
The Geriatrics, Interprofessional Practice and Interorganizational Collaboration (GiiC)
Initiative: Enhancing Shared Care of Frail Seniors

The GiiC initiative is a collaboration of the Regional Geriatric Programs of Ontario
located in Hamilton, Kingston, London, Ottawa and Toronto, the Centre for Education
and Research on Aging and Health (CERAH) at Lakehead University in Thunder Bay
and the North East Specialized Geriatric Services (NESGS) Group in Sudbury.

The GIIC is a network of excellence in practice based interprofessional education and
interorganizational collaboration in primary care that will support the academic initiatives
outlined in the HealthForceOntario, Inter-professional Care: Blueprint for Action and help
the province in managing the consequences of its ageing population.
The primary outcomes arising from this initiative are as follows:
1) The consolidation of a team of GIIC resource consultants situated within the RGPs of
Ontario, the Centre for Education and Research on Aging and Health at Lakehead University
and the North East Specialized Geriatric Services Group in Sudbury to train coach and
mentor a provincial network of GiiC facilitators.
2) The development of a province-wide network of 200 GiiC facilitators situated in Family
Health Teams (FHT) and Community Health Centers (CHC) to assist their teams and
organizations in the delivery of collaborative shared care to frail seniors.
3) A set of GIIC teaching resources and facilitation tools with an online repository
4) An intersectoral and province-wide health services workforce with enhanced awareness
and knowledge of each other and higher levels of skill in the three competencies
5) A sustainability plan for each network hub consistent with each group’s specific needs and
leveraging existing resources and skill sets
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6) Improved shared health care for seniors and especially frail seniors
The Sunset Country Family Health Team (Kenora):

Is here to help improve your access to health care and quality of care for you and your
family.

Will provide you with a team of specialists to assess your health needs, provide
preventative care to help you stay healthy, provide care for chronic conditions, and coordinate your health care with other agencies.

Will help you manage the challenges of living with chronic illnesses including high blood
pressure, high cholesterol, stroke, heart conditions, and diabetes. We will help you
manage your symptoms by: monitoring your chronic illness, showing you how to live
more actively and how to eat well, showing you how to use your medications safely and
effectively, showing you how to set and achieve goals to improve your well being. We
are also providing group programs.

Will provide preventative care including up to date immunizations, regular health exams,
disease screening, nutritional counseling, diabetes prevention counseling, and exercise
counseling, smoking cessation techniques.
St. Joseph's Care Group (Thunder Bay)

St. Joseph's Care Group includes: St. Joseph's Hospital (Corporate Office), Balmoral
Centre, Behavioural Sciences Centre, Diabetes Health Thunder Bay, Hogarth Riverview
Manor, Lakehead Psychiatric Hospital, Sister Margaret Smith Centre, St. Joseph's
Health Centre and St. Joseph's Heritage. These facilities are owned and operated by the
Sisters of St. Joseph of Sault Ste. Marie, sponsored by The Catholic Health Corporation
of Ontario (CHCO) and managed by a volunteer Board of Directors.

Together, we are committed to providing programs and services in complex care and
rehabilitation, long-term care, supportive housing, and, mental health and addictions to
meet the needs of the people in the Districts of Thunder Bay and Kenora-Rainy River.
Sioux Lookout Meno-Ya-Win Health Centre

Is a fully accredited, combined 36 acute care bed, 5 chronic care bed hospital and a 20
bed Extended Care facility, including the Community Counseling and Addictions
Services Program.

Provides health services to all residents within Sioux Lookout and the surrounding area,
including the Nishnawbe-Aski communities north of Sioux Lookout, the Treaty #3
community of Lac Seul First Nation, and residents of Pickle Lake and Savant Lake.
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
"Meno Ya Win" in the Oji-Cree language means "health, wellness, well-being", and
refers to holistic healing and wellness, the "whole self being in a state of complete
wellness".

At Sioux Lookout Meno Ya Win Health Centre:
-
We serve approximately 30,000 outpatients on a yearly basis;
-
SLMHC employs 300 people;
-
SLMHC has 8 locations throughout the town;
-
SLMHC will operate in "a state of the art" health care facility located within a
health park setting in 2010.
Take Heart Coalition
Take Heart Mission Statement
Take Heart is a collaborative effort to promote community awareness of healthy lifestyle
choices, and to encourage behaviour changes throughout the District of Thunder Bay.
Supportive environments will be created through a coordinated network of policies, facilities,
education, and service providers.
Take Heart Projects
Take Heart Coalitions are established in communities across the District of Thunder Bay:
Thunder Bay, Nipigon/Red Rock, Municipality of Greenstone, Schreiber/Terrace Bay, Marathon,
and Manitouwadge. These coalitions are responsible for organizing projects that promote
healthy lifestyles in their community. Many thanks to the volunteers and organizations working
hard to make a difference! Take Heart is part of the OHHP - Taking Action for Healthy Living
initiative, is funded by the Ministry of Health and Long Term Care and coordinated by the
Thunder Bay District Health Unit.
Maternity Centre of Thunder Bay Regional Health Sciences Centre
The new Maternity Centre, built in the Medical Centre adjacent to the Thunder Bay Regional
Health Sciences Centre, is approximately 5,900 square feet and will see individual
Obstetricians, Family Practitioners and Midwives working within a “bookable” space to see their
obstetrical patients.
 The Centre will also be staffed by a variety of support professionals including a Social
Worker, Lactation Consultant, Diabetic Educator and Dietitian; and, recognizing our
unique cultural demographic, a Native Liaison Worker to ensure efficient access to the
appropriate level of service and the associated care provider. A smoking cessation
program will also be offered.

Support services are offered on a one-to-one basis and in group sessions. Examples of
group sessions include monthly breastfeeding and “Healthy Weights Postpartum”
classes. Referral to the Maternity Centre Support Services can be made through your
obstetrical care provider. Talk to your health care provider about the various services;
contact the Maternity Centre Reception Desk directly at 684-6228 to discuss availability,
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or check for postings regarding upcoming group sessions, on the Maternity Centre
information board, at your next visit.
NorWest Community Health Centre (Thunder Bay)

The NorWest Community Health Centres provide health care and health promotion
programs in Armstrong, Longlac, and in Thunder Bay. As part of a network of 56
Community Health Centres, we have been providing services for more than 10 years.

We make special efforts to serve people who have a higher risk of poor health, or people
who are having difficulty finding health care because of language, cultural barriers,
poverty or isolation. We consider the social, emotional and financial needs of our clients,
since these factors affect a person's health. Our team features family physicians, nurses,
nurse practitioners, counselors, dietitians, nutrition workers, community health workers,
early childcare educators, and support staff. We offer confidential services free of charge

We strive to involve community members directly in planning and delivering programs.
Peer leaders and volunteers from the community help develop and lead programs. We
partner with a variety of service providers to find the most efficient ways to deliver
services.

The Ontario Ministry of Health and Long-Term Care funds the NorWest Community
Health Centres. A volunteer board of directors governs our operations. Programs are
free and confidential.
North West Local Health Integration Network Health Human Resource Roundtable

This group will serve as an enabler to the NW LHIN Advisory Teams and the work of the
LHIN, identifying and supporting innovative models of service delivery and aligning with
the work of HealthForceOntario.
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Appendix B: Wish List
For the sake of brevity, this wish list does not include inferred wishes (for example from
discussion about challenges), but instead just those comments that were explicitly wishes. As
much as possible these wishes are in the words of the participants. While some of these wishes
could be possible recommendations, it should be remembered that the participants offered
these as wishes. If they don’t have the pragmatism of a recommendation, they nevertheless
help paint the vision of where IPE and IPC could go. An attempt was made to categorize these
under the headings of the previous model, but as noted in the limitations, many of the
comments straddle multiple interrelated categories.
A. Wishes related to educational system







That every single course at the undergraduate level, for our university anyways, would
have a component of the curriculum focused on IPE…..so the message is loud and
consistent that an important part of their professional role is understanding the other
professions and the way to do it is collaborative practice.
That in-service learning about the other professions is important [and thus incorporated]
because if you don’t continue to have that dialogue, once we are practicing people will
soon forget and we will get back to our silos…
That we had more courses like intro to dementia or intro to palliative care (i.e. theme is
on the type of care and therefore less discipline related). Students would then bring their
discipline specific knowledge to the course and share these with the other students. This
would be problem based learning, but with multiple disciplines.
That medical students are included [in the many Lakehead IPE initiatives], particularly
when you consider that medicine is often viewed as the leader of health care.
That students could recognize that group work skills are particularly needed once they
enter the workforce. Currently enthusiasm or comfort level for shared work is lacking.
That there was education not only in the schools but in the care settings to support the
knowledge sharing around roles and scopes and all of those sorts of things so you begin
to appreciate and understand.
That there would be more of the collaborative education piece and more of the sharing
of learning so that when there is an IP event [which is] sometimes impromptu and not
formalized…people can see that this [IPC] actually can work…
B. Wishes related to the professional system (including government funding system)


That the LHIN will be able to move this [IPC] forward through funding arrangements and
contracts with organizations that are providing the care.
That since there is a blueprint for IPE/C put out by the Government, that a regional
strategy of the LHIN could be that in order to receive funding, or increased funding for
their programming, all health care and education facilities had to have a plan of action
and yearly goal setting that included an IP strategy and practice delivery. [This should
be] an initiative, not a punishment. [For example] award the organization that develops
the best plan that can be disseminated to other organizations for IP practice and
education in their organization, and the others have to go on board in 2 or 3 years…
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Appendix B: Wish List (cont.)







That Family Health Teams come under the direction of their local LHIN as their LHIN
would be more responsive to local needs than the current FHT- MOHLTC model.
That we would stop worrying about accountability and proving ourselves and let people
do their jobs.
That when I look and see how overworked physicians feel they are, that as a profession,
they could get to a place where they could just relinquish some of the control and realize
that they would still have an acceptable quality of life, financial quality of life and there is
enough work to go around.
That we try to push the system further to dismantle, if necessary, some of the vested
interests of specializing services that I think work against an efficient flow in support of
care provision in a primary care setting.
That the hospital role will have to be dismantled a bit too, because we already have an
increase in outpatient services and it would be a natural evolution that you don’t have to
see the orthopaedic surgeon at the hospital. They will be there for some inpatient
operation that has to be done in a sterile environment and all those things, but they
would further use hospital spent money at a community level, whether it is prevention,
whether it is smoking cessation, safe driving at a prevention level, strategies to intervene
early on psychosis, depressive episodes, getting people back to work or keeping them
working.
That the paranoia around accountability would go away.
That we continue to work with the LHIN in developing working relationships with the First
Nations in the communities…that we somehow do away with the jurisdictional barrier
that most of the First Nations are under Federal jurisdiction because it is the nursing
stations that is their primary access to health care.
C. Wishes related to the social/cultural system



That society would understand the problems that marginalized people have, the
suffering that they have and that one human is equal to one human and they are human
beings that require caring and services. Wish everyone could understand what our staff
understands, so then we wouldn’t have to justify our existence…then our people would
be OK because we would get more services and all that other stuff would happen.
That as a society we see that [directing funds to prevention] as more of a priority and
that we deal with people who are sort of on that slippery slope of life and that is going to
end them up, because of work habits and diet and nonexercise and all of those things,
that they will be part of what the resources go towards and that is the sick.
That there is a culture change to support collaborative care. The culture change I guess
can be summed up that if there is a will there is a way and that goes for the care
provider; that goes for the decision makers; that goes for the politicians and the
Ministries.
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Appendix B: Wish List (cont.)
D. Wishes related to coordination & communication mechanisms











That there was a structure or identified function that brings the team together. This
could be a different person in different settings, but this person would act as a case
worker or a personal coach. This challenge would also be faced in coordinating
community resources…
That we had better electronic medical records. The current Meditech, despite the
huge investment, is not conducive to collaborative planning. There is no part of the
record where it is reasonable for all professions to review.
That … even though we may care for the same patient, it would be nice to assign
patients to a care provider instead of having people floating without anyone taking
ownership or responsibility for at least there would be some kind of quality
assurance, where you would have responsibility for a limited number of patients,
instead of working in a centre where basically no one is taking responsibility.
That we can build in more flexibility with the academic institutions… [to allow for
example] to have two groups [of placement learners] together at the same time or
nurses graduating in December and working under the graduate initiative prior to the
beginning of the vacation period.
That we have think tanks or opportunities for the heads of organizations involved in
primary prevention to meet and discuss ways to move forward.
That we have a chance for executive directors involved in various sectors in the
community to meet and strategize around policy that promotes wellness and
improves health behaviours (e.g. might want executive directors from Cancer Care
Ont., LHIN, Health Unit, Community Services and City Engineering to strategize
together).
That we include the population we are trying to serve in our decision making.
That everyone has bought into it [a system of coordinated access to community
resources] and there is cross promotion and cross support for that individual to
access all of those resources within the community.
That a case study conference, and I think the LHIN could put something like this on,
that dealt strictly with case studies around health care issues…and you invited health
care workers from all levels to come and sit on problem solving teams and come up
with ways and strategies to handle these particular cases which actually reflect
events that happened in the community.
That grey literature and best practice research is more easily accessible.
That the individuals from the homeless shelter could have a meal at the hospital (as I
am sure most places waste a lot of food), because without proper nutrition a lot of
these people can’t heal.
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Appendix B: Wish List (cont.)
E. Wishes related to team resources
E.1. Time
 That more resources are available to professionals who are already practicing to
have a part of their week, or a part of their job description to be focused on IPE
development, because right now for most of us that are doing it, it is really just an
add on.
 That there would be support, not necessarily financial, but you are going to need
some time and resources to develop some of these innovative programs. People just
can’t do it on top of what they are already doing. There needs to be some flexibility
so that you can actually make the change.
E.2. Human
 That there would be a one-stop shopping experience for patients [meaning all care
needs are serviced in one location]. They would come in; they have their needs
taken care of on site as pleasantly as possible, without them having to go multiple
places. [e.g.] One of the things that would make my life easier here is if we could
have access to child care while the mother either attends to some education things
or attends her appointment.
 That we had more nursing staff…so we would have more opportunity for education,
more opportunity for patient education and more opportunity to just spend time with
the patient and actually having time for them to tell you things, because a lot of times
they don’t because they know you are really busy.
 That we didn’t have such long waits for some specialists.
 That we had more money for more staff so we could do more outreach…not just
physicians and Nurse Practitioners, but community health workers and foot care and
mental health counselling…to be able to go to the hard to serve areas of our
community.
 That with the gerontology piece, to allow more hours than the 14 hours allowed for
the homemaking services of CCAC [Community Care Access Centre]. That would be
phenomenal because the people requiring that service need it to stay at home. With
that would come a transportation piece where individuals who do not have a friend or
family member in their care are assigned one. Not a case manager role, which is
document, document, document, but more of a doer who is able to attend those
appointments; is able to be a point person and help with the coordination piece…
E.3. Space
 That [we had IP space] for:
- A common triage area for the nurses to prepare the patient prior to going to see the
doctor
- A meeting room or teaching area
- A teaching kitchen
- A patient friendly environment (waiting room, wheel chair accessible)
- Larger offices for IP discussions
- Larger examining rooms (appropriately supplied and equipped) for IPC
 That the new hospital [in Sioux Lookout] has a big enough facility so that we can all,
once a month, do interprofessional or interdisciplinary rounds.
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Appendix B: Wish List (cont.)
E.4. Financial
 That we have dedicated resources [in the academic institutions] to see these
[initiatives such as IP student placements and a December graduation for Nurses]
through. That the government needs to say, OK education is an important piece and
the service provider needs resources to do this, then they have to put resources in at
all levels.
 That [the Ministry] would give us [the Maternity Centre] permanent funding and let us
proceed because we are doing great things.
 That we had a pool of flexible resources that is housed in an organization and the
purpose of those resources is to put that money towards creative solutions for people
who are really complex and have multiple needs.
 That there would be funding for an escort when people come down from up north to
have babies or to receive palliative care.
 That there is some resourcing put towards health care lifestyle clinics.
F. Wishes related to organizational philosophy







That we have more patient centred care and therefore effective patient education to
empower the patient and provide them with the skills to coordinate their care.
That we can identify with a patient and work collaboratively with a team as to what a
patient means…and trusting that everybody is going to do their role…and then you
feel good at the end of the day and then the outcomes are improved because of it.
That HealthForceOntario broaden their definition of interprofessional care to be more
encompassing of wellness.
That there is recognition of primary prevention as a key piece of the health care
continuum and not to have it compartmentalized either within an organization or
outside of healthcare discussions.
That a stronger case is made to the Ministry as to how finances can be saved by
broadening their perspective to include prevention.
That the decision makers [as opposed to just the front-line workers] in all of the
sectors [recreation, municipal, workplace, education, community agencies] have this
sense of ownership; that healthy eating and physical activity and smoke free living
and stress free lives for whoever they have control over is important.
That we will have ongoing development of the vision that Meno-Ya-Win [Health
Centre] is already developing around interprofessional care and having that being
reflected in things like grand rounds once a month that would have a topic that
everyone would come to.
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Appendix B: Wish List (cont.)
G. Wishes related to organizational structure



That once students go out in the workforce, they find Champions of IPC. If they don’t
find an IP setting, they may feel disillusioned and that the IP learning was a waste of
time.
That there is ready access [to care]…a warm and inviting environment and patients
are not inconvenienced.
That, modeled after the program management approach [as opposed to discipline
specific departments]…there were dedicated teams of professionals in IP teams that
really dealt with programs or groupings of patients that therefore would know the
capacity and trust and communication and all those processes within those
teams…really build that whole program approach across any organization.
H. Wishes related to administrative support

That we could enthuse managers in health care to come out to sessions like this
where they see IPE, because if they are the leaders and if they don’t believe in IPE
and don’t see the value of IP clinical delivery, then it is not going to happen.
I. Wishes related to willingness to collaborate in a patient centred model


That, since the successes that I’ve been involved in have all been because they
were built on an articulated need, we look for opportunities to develop IP based on
articulated needs in the community or what have you; not just we’ve got IPE, let’s try
to inject it somewhere…
That people generally go along with self management and when you consider the
patient centred model, it is really putting the responsibility back on the patient or
client and they must have a sense of ownership for their own health.
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References
D'Amour D, Oandasan, I (2004). In Oandasan et al. (eds). Interdisciplinary Education for
Collaborative Patient Centred Practice. Ottawa: Health Canada.
HealthForceOntario, Interprofessional Care: A Blueprint for Action in Ontario. Interprofessional
Care Steering Committee, July, 2007, www.healthforceontario.ca
Jubber, V., Building Quality and Efficiency Lessons Learned- the Chinook Experience, Slide
presentation at the NW LHIN Building Quality and Efficiency: Together We Can workshop,
Thunder Bay, ON, March, 2009.
Ontario Health Quality Council, http://www.ohqc.ca/en/index.php
San Martín-Rodríguez L, Beaulieu MD, D'Amour D, Ferrada-Videla M, The determinants of
successful collaboration: a review of theoretical and empirical studies. J Interprof Care. 2005
May;19 Suppl 1:132-47
Wolff JL, Starfield B, Anderson G. (2002) Prevalence, expenditures, and complications of
multiple chronic conditions in the elderly. JAMA, 162: 2269–2276.
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