Implementing Family Medicine Groups: the challenge of reorganizing practice and fostering interprofessional co-operation - Case Study in Five First-Wave FMGs in Quebec

Key Implications for Decision Makers

Over a two-year period, this study assessed the implementation of five family medicine groups (FMGs) that were part of the first wave in implementing this policy in Quebec. The study focused on how operation of the group redefined the group's practice and co-operation among professionals; it also examined the results of this redefinition for the enrolled clients.

Implementation of the first accredited family medicine groups proceeded in asynchronous phases and did not always clearly define the initial distribution of roles. The professionals in the five groups studied did not always have the necessary support and levers and thus occasionally felt they were left on their own to organize and manage the changes they had to implement.

Despite certain difficulties, positive changes were observed within the five family medicine groups studied in the values and practices of professionals, development of their co-operation, and improvement in the various aspects of user services.

Development of a joint vision of the group's objectives was promoted by the rallying effect of internal leadership. The support provided to the group by external leadership at the regional (regional departments of general medicine) and provincial (especially the Quebec Federation of General Practitioners) levels also appeared to be essential.

The development of joint monitoring protocols for some chronic diseases also proved to be an important tool for persuading physicians and nurses to work together closely and get to know each other better. This mechanism helps instil trust between partners and fosters the development of co-operation. The same holds true for the various tools for promoting dialogue between professions, such as group meetings and patient monitoring committees or forms.

On the other hand, the establishment of family medicine groups at several sites adds difficulties that are both logistical (finding common meeting spaces) and "conceptual," related to the process of harmonizing practices. In fact, the diversity of medical practices (especially as this relates to multidisciplinary practice) poses obstacles to defining a joint vision of the group and establishing interprofessional co-operation.

Co-operation between physicians and nurses is promoted when physicians share a joint vision of the role of nurses, view them as collaborators rather than assistants, and when nurses have an opportunity to demonstrate their specific skills and the added value they provide. When this co-operation is genuine, we find that practices in both professions enrich each other.

These changes in practice and this interprofessional co-operation have been viewed positively by enrolled clients. Improvements have been noted in the following areas: accessibility during office hours, accessibility after office hours, co-ordination between physicians and nurses, the comprehensive nature of care, and knowledge of the patient.

Executive Summary

A family medicine group (FMG) is a new organization composed of family physicians working as a group, in close co-operation with nurses, and providing an extended range of services to clients who have enrolled of their own free will. The group policy focuses on enhanced accessibility, multidisciplinary teams, and information technology, characteristic of the various Canadian initiatives designed to reorganize primary care and co-ordinate that care more effectively with the entire system. However, it makes no significant change to the way physicians are compensated and the terms governing client enrolment are not very restrictive.

By adopting the approach of reorganization of work and co-operation between professions, this two-year study assessed the implementation of five family medicine groups that were part of the first wave in implementing this new policy in Quebec. The study examined how operating in groups redefined the group's practice and co-operation among professionals (among physicians and between physicians and nurses); it also focused on the results of this redefinition for the clients enrolled. The data were obtained from 106 personal interviews of professionals and managers, survey questionnaires administered to 2,755 patients and 88 professionals, focus groups consisting of 22 patients, and analysis of documents (letters, memos, care protocols, etc.).

Findings and implications

Family medicine groups were created in a very political context and were implemented on an accelerated timeline that was not always synchronized. Design and engineering of the group policy occurred simultaneously with implementation in the field. This situation created serious tension among the first groups selected, which had to embark on major change and take on the attributes of a new model for organizing practice while lacking the necessary levers and support.

Implementation dynamics

Two main visions of family medicine groups encourage physicians to join. One is based on an ideal of practice (broader responsibility for clients, more continuous service delivery and enhanced accessibility), while the other is more pragmatic (sharing of duty hours, coverage of unpopular hours, etc.). Physicians also take a different view of the role of nurses in a family medicine group, ranging from an expanded role characterized by autonomy to a role that "accelerates" the production of care. In each group, these visions exist together (to varying degrees) and have proved to be a source of tension for some groups.

The implementation of family medicine groups requires a levelling of frequently diverse medical practices (practice habits, institutional traditions). This increases the challenge of harmonizing practices. Despite these challenges, the group's practice developed or was consolidated, to varying degrees, in all the groups studied. This emergence of a group practice does, however, require tools, one of the most important being the co-operative work required for developing care protocols.

Enrolling clients in family medicine groups proved much easier than expected. Many believe, however, that the targets set by the health ministry disregarded factors such as special client characteristics or the diverse practices of physicians.

Service delivery in the family medicine groups studied, despite the co-existence of occasionally differing visions and diverse practices, did not result in serious disparities as might have been expected.

The main obstacles to implementation were:

  • a cumbersome government process for implementing family medicine groups;
  • contractual agreements, especially those surrounding the hiring of nurses (who maintain a bond of employment with the CLSC);
  • information systems, which were slow to be introduced and which disappointed professionals who viewed this as a serious lack of support for implementation; and
  • lack of support for the process of change, which was a criticism in all the groups studied.

The main assets for implementation were:

  • funding and the role of support staff (secretary and administrative technician);
  • regional project managers, a functional that paradoxically stopped being funded once accreditation was obtained;
  • support of the Quebec Federation of General Practitioners; and
  • the presence of strong leadership within family medicine groups, consistent with the thrusts of the policy.

Interprofessional co-operation and clinical practices

Over the two years of the study, co-operation between physicians and nurses improved noticeably in four of the five groups studied. Sharing of responsibilities emerged to varying degrees and in varying forms within each group; the boundaries of co-operation are determined by how physicians and nurses see their respective roles. This is a healthy situation that supports the development of co-operation consistent with the pace of the professionals, but it places demands on nurses who must adapt to various modes of interaction with physicians, and can prove difficult where physicians do not allow them to achieve their full potential.

In family medicine groups where the development of co-operation is most advanced, leadership, trust, and formalization (protocols) are emphasized. In groups where co-operation is less advanced, poor development of outcomes for the group and for the concept of co-operation with nurses is obvious. Trust lies at the heart of co-operation among physicians and between physicians and nurses. It is based on a perception of trust in others and is linked to knowledge in one's field of practice. The formalization of care protocols is also central to co-operation: in group development periods, it gives professionals the opportunity to get to know each other better and to negotiate the sharing of responsibilities. The same is true for the tools that promote dialogue among professionals, such as statutory meetings and meeting of physician-nurse subcommittees.

Development of nursing practice in family medicine groups

In the area of clinical work, we note two types of practice, exercised to various degrees in each group. The first type (continuous care, monitoring of chronically ill patients using a comprehensive approach) was found to be more important in groups in a CLSC and in a family medicine unit. The second type (ad hoc care, to support the physician) proved more important in groups in a private practice.

In the area of teamwork, four main points must be noted: case discussions are informal rather than formal; with one exception, nurses take part in group meetings; monitoring protocols are developed based on the needs of the group; and, with one exception, nurses hold clinical meetings.

Ethical considerations

Consolidation of the group model has led professionals to question what motivates them to practise their profession. From the nurses' perspective, groups were perceived and experienced as a place that allows deployment of a practice centred on professional autonomy. The moral dilemma that concerns professionals is conflicting loyalties, in a context of limited resources, between enhanced access to a family physician for the public in a given territory and improved continuity and quality of care for group clients.

The patient's point of view

The survey found that most users see only benefits to enrolling in a family medicine group. Some family physicians feared nurses' participation in joint intake of various client groups. The survey and focus groups suggest these fears have proved groundless.

Thus, in general, we find improvements in the following areas (by order of extent of the improvement observed): accessibility to after office hours; accessibility during office hours; co-ordination between physicians and nurses; comprehensive nature of care; and knowledge of the patient.

Discussion of findings

The policy that gave rise to family medicine groups was demanding in several respects and targeted broad, ambitious goals covering all primary care that affected far more than these groups alone. The clinicians required to implement that policy did not have all the levers and support needed to achieve all the characteristics associated with the reality of a group practice.

Yet the implementation of family medicine groups did foster real change in primary care medical and nursing practices. This supports the idea that a modest but targeted investment (such as the group policy, which was pragmatic, gradual, and relied on existing modes of organization) is more likely to bring about change than a comprehensive project for change that is often detached from operations and the organization of work in clinical settings, even if all the conditions for success are not present.