What outcomes may be seen from promoting the leader-follower relationship quadruple aim

Table 2 provides information about participants and data sources by case. In one case, focus groups ‘A’ and ‘B’ were combined per the organization’s request. Forty-two focus groups and 12 individual interviews were completed. Seventy-three people participated in focus group A, 80 in B, and 8 in the combined focus group. Overall, there were 328 participants including 59 physicians, 182 nurses, 8 occupational therapists, 12 business administrators, and 67 others (e.g., nurse practitioners, community developers, social workers, occupational therapists). PSATs were completed by 7 to 14 participants per case (total n = 98) with a completion rate ranging from 36 to 100% per case. Seven cases had a response rate of 65% or greater within 30 days required for valid results [31].

Professional disciplines involved in collaborations included: public health nurses (PHNs), nurse practitioners (NPs), family practice nurses, PC physicians, Medical Officers of Health (i.e., public health physicians), mental health workers, administrators and managers, occupational therapists (OT), speech therapists, social workers, midwives, information technology experts and operations staff (e.g., clerks, receptionists). Populations served often had limited access to PC or PH services and/or were disadvantaged due to lack of stable housing, poverty, discrimination and stigmatization, poor mental health, trauma, or violence. Collaborations also engaged in immunization programs and vaccine management that served the population-at-large. Other populations included youth, women, or adults in rural communities living with mental health problems or addictions. Some cases focused on building service provider capacity in health promotion.

Collaborations, at times, developed organically in response to community needs and a mutual sense of responsibility to address them. In other cases, they developed formally as partnering agencies worked together on strategic plans, set goals, identified priorities, and participated in steering committees. In some cases, goals and priorities were refined over time through ongoing meetings with providers and community groups.

There were varying precipitators that supported initiating a collaboration. Potential partners often shared a common vision and/or community concern. They perceived that working together could have a greater impact by using resources differently, addressing community problems together, or offering alternative solutions to meet service demands. Some collaborators saw opportunities to increase effectiveness and/or maximize efficiencies, since they worked with the same populations. Tipping points that enabled action on collaboration related to provincial funding incentives for new initiatives or ways of practicing to address common concerns.

There were four key foci for collaborations. These included: provider capacity building; regional vaccine /immunization management; community-based health promotion programming; and, increasing access to care through outreach programs and services. We identified common inter and intrapersonal, organizational and systemic enablers and barriers to collaboration. Common enablers included personal skills, knowledge and attitudes that supported the collaboration, clear roles, effective communication and coordination strategies, strong organizational leadership, formal agreements, human resources, and provincial mandates that were aligned with collaboration aims. Common barriers included turnover of staff, lack of role clarity, lack of resources and funding for collaboration, and a lack of support from the provincial government.

Detailed case descriptions

Detailed results are presented by case (see Additional file 3) describing aims and motivators for collaboration, provider activities, and perceived outcomes. In addition, we present key collaboration barriers and enablers organized under systemic, organizational, interpersonal and intrapersonal factors influencing collaboration. Cases were organized by categories based on common goals including: Cases 1 to 2 - provider capacity building; Cases 3 to 4 - regional vaccine /immunization management; Cases 5 to 7 - community-based health promotion programming; and, Cases 8 to10 - increasing access to care through outreach programs and services. Relationships to the Q-Aim framework are highlighted. Table 3 illustrates the intensity of activities (i.e., minor focus [+], moderate focus [++], or major focus [+++]) conducted in each case demonstrating how they worked together. A description of each case by category follows and the most compelling links to the Q-Aim framework are acknowledged. Sources of quotes are identified by case number, sector (PH, PC, Community or both PC and PH), and discipline (e.g., PHN, MD, Other).

In two cases, partners engaged in provider capacity building to address client needs. Improving provider confidence through professional training can indirectly address the Q-Aim – improving the provider experience and ultimately patient experience.

Case 1 began with PC’s desire to develop provider capacities in working with at-risk children. A PHN was seconded to the PC practice located in a large urban setting with multiple practice sites to build PC provider capacity in conducting enhanced 18-month well baby assessments. The collaboration also was a means of rekindling historically positive PC and PH relationships that could lead to future collaboration:

… Both [PH and PC] felt that the relationship between the two sectors had eroded and historically we’d had a very close relationship. […] So whatever strategies we were using to date weren’t working. […] So, the collaboration was really designed to address all of those things. [Case 1 PH-Other]

Enablers were related to high levels of trust between PC nurses and the PHN, having a formal contract, and funding for the secondment. Barriers included physicians’ perceptions of being excluded from the development of the collaboration and the lack of compensation and protected time for PC nurses to attend training.

Case 2 involved a PHN working closely with a PC NP in a rural PC practice with satellite locations to train PC staff on comprehensive tobacco cessation. Provincial funding for staff and resources provided the tipping point for the collaboration. Mutual interests determined collaboration goals.

… “our combined goal was really to get a good comprehensive strategy embedded in the [PC team] and to reach out to the community as well… As [NP] was saying, to educate front line staff so that everybody was coming from the same place and had a good solid understanding.” [Case 2 PH-PHN]

Collaboration enablers included: a clear provincial mandate for both sectors to work on tobacco cessation, clear roles, strong past relationships, shared material resources and space, as well as a local award celebrating the collaboration. As in Case 1, there were inequities for PC nurses who were paid through a special funding envelope that made them ineligible to attend training.

Regional vaccine and immunization management

Two cases focused on increasing immunization coverage rates for geographically distinct regions. They addressed two Q-Aims - improving population health and reducing costs by creating operational efficiencies.

Case 3 involved coordination of a regional flu campaign using a shared electronic health record and appointment system. A PC organization serving most residents in a small northern community collaborated with PH to enhance immunization coverage supported by community members. Participants saw collaboration as a means of reducing duplication while improving efficiencies and addressing partner’s reporting needs. Previous ineffective immunization campaigns highlighted the need to collaborate:

…the collaboration started out of desperation, to be honest. We needed to get vaccine into people’s arms and neither one of us could meet the demand... […] I’m sure it came out of discussions at meetings… [Case 3 PH-PHN]

Enablers included strong relationships and trust among providers and community members who had previous working relationships, a common vision among organizational leadership, a formal partner agreement, provider training on the Electronic Medical Record system to track immunizations, optimizing human resources (e.g., PC expertise in IT systems and PH’s expertise in immunization). Barriers included the legacy IT system and a lack of community volunteer engagement to assist in implementing the campaign.

Case 4 served a mixed urban-rural region and involved PC and PH exchanging paper-based immunization records to increase accuracy in records, tracking immunization coverage, and reducing vaccine wastage.

…we have the hope that within x number of years, we will have immunization information on every child who’s in school. That automatically will come to us because of the partnerships that we have now. [Case 4 - PH-PHN]

A PH driver delivered vaccines to participating PC practices, exchanged immunization records, inspected for cold chain breaks, and connected PC staff to PHNs in the communicable disease program to answer clinical questions. A manager reported significant reductions in vaccine wastage and recognized opportunities to improve information systems through cooperation.

Enablers included positive personal characteristics of the PH and PC providers (e.g., knowledgeable), effective interpersonal communication, strong coordination and communication processes, PHNs assigned to work with PC, strong PH leadership that included conflict management skills. A barrier was the time required to build PC PH relationships in the region.

Community-based health promotion programming

Three cases involved community-based health promotion programming in rural communities that addressed two Q-Aims – improving the patient (client) experience and improving population health. Case 5 involved a solo practice physician working with community agencies (i.e., PH, community members, researchers, local and regional governments, NGOs, First Nations communities, and parks and recreation) in a geographically-dispersed rural setting. The collaboration focused on youth health, mental health, food security and social determinants of health. A steering committee consisting of community members and service providers was instrumental in spearheading the collaboration. Terms of Reference included access and inclusiveness goals and collaborators promoted a seamless network to improve care processes:

… to make it easier for all the information to get around to the various organizations and for them to collaborate or for them to network. [Case 5 Community-Other]

Recognition of community needs and service gaps and research funding helped solidify working relationships to address population health:

... a group of community service providers got together to address the abysmal lack of mental health and addictions services in the community. From that table … arose the idea of a community-based participatory action research project. So, over a course of two years we acquired funding and developed a new role and a community mental health service access and a mental health service navigation… [Case 5 PC-MD]

Collaboration enablers included individual skill sets and personal commitment to address the common goal, appreciation shown for volunteers, open and transparent discussions, and collaboration champions. Barriers included varying organizational goals and philosophies, the informal collaboration structure leaving it vulnerable, challenges in scheduling geographically dispersed meetings, and competition for scarce system level resources.

Cases 6 and 7 aimed to improve access to health promotion and illness prevention for specific populations through a client-centred approach by matching resources to individual, family, and community needs. Case 6 focused on rural women, and like Case 5, motivators included concern for families ‘falling through the cracks’, inequities, and gaps in services:

It was an opportunity to provide services to women in a better way, in a more responsive way to [address] the needs of the individual in a setting that was more comfortable for the individual person coming in. […] So, it was really around trying to do a better job for an under-served population of women and adolescent girls. [Case 5 PC-Other]

A non-government organization led the collaboration among PC, PH and other agencies in a shared space. Enablers included individuals’ strong belief in and commitment to women-centred care, flexible roles that matched providers’ skills, having formalized agreements and operational plans for the collaboration, and regular committee meetings. Barriers included finding a good fit for PH providers in a PC setting, high staff turnover, a lack of cash resources, and system level mandate changes resulting in provider role confusion.

Case 7 emphasized infant, child, and youth health. Collaborators conducted joint planning to address immunization program inefficiencies while offering comprehensive programming working with community members. This rural collaboration developed through formalized conversations that helped partners recognize common community concerns:

It’s that groundwork that you need to do upfront, setting those goals, coming as a collective, having those conversations that bring you to the same place, having a common commitment and understanding […]of what needs to happen. [Case 7 PH-Other]

Enablers were joint training and meetings, and leadership to drive the collaboration. Barriers included conflicting PC and PH mandates and changes in mandates that contributed to role confusion. Similar to Case 6 the collaboration had high staff turnover and PC struggled to find time for the collaboration due to heavy work demands.

Increasing access to care through outreach

Case 8, 9 and 10 applied an equity lens to increase access to services for hard-to-reach populations through outreach best aligning with the Q-Aims – improving the patient experience and population health. Case 8, a social pediatrics initiative provided outreach services emphasising health promotion for at-risk children and families (i.e., poor, exposed to substance use and/or family violence) in a large urban centre. Service gaps for hard to reach, at-risk families, and a lack of PC physician access motivated PC NPs to provide outreach and service coordination. They offered services to young families at community locations (i.e., schools), and referred to a tertiary care centre for specialist services, PH and other health and social services:

We’re trying to make it a low barrier system so that if you go into the community center and you need health care, the community center can help you get to health care. If you go into PH and get immunizations and you need some developmental assessment or you need some kind of maternal mental health assessment, you will get linked that way. […] every door is a way in. [Case 8 Community-OT]

Enablers included individuals’ personal commitment to the initiative, a publicly shared role definition for the NPs, knowledge of who to approach to address issues, and engagement of partners and community members/clients at community tables. Barriers included differing philosophies and communication modes among partners, a lack of leadership buy-in, and no overall leader.

Case 9 was an inner-city outreach program for street-involved population. A coalition of community organizations, including PC and PH, followed a project charter with service objectives including communicable disease control, outreach, disease prevention, treatment and referral, addictions and mental health counselling. Shared concerns for those without access to services moved PC and PH providers to collaborate without formalized relationship agreements:

...we haven’t embedded routine sharing arrangements; that sort of happened almost automatically. [Case 9 PH-MD]

Enablers included capable, skilled front-line staff, respectful interpersonal relationships, and interdisciplinary teams that brought different strengths. Barriers included a lack of role clarity between PC and PH providers exacerbated by changing PHN roles, and no common communication infrastructure.

Another urban outreach program, Case 10, served a street-involved population focused on improving immunization coverage against influenza. PHNs gained access to ‘the street’ through PC nurses who were trusted in the community. PC nurses, PC and PH physicians, PHNs, managers, and administrators shared a passion for equity and social justice and strong desire to reach the underserved:

… this is the population that nobody else really takes care of. And so [managers and directors] are very supportive of us providing these services and involving our front-line practitioners, or our PHNs to be involved. [Case 10 PH-Other]

Enablers included individuals’ passion and skills in working with marginalized communities and a commitment to equity and social justice. Previous working relationships were helpful, and a lack of a formal agreement allowed for more flexibility in the collaboration. Communication was informal challenging busy workloads. In-kind resources were enablers given the lack of provincial level funding for the collaboration.

Impacts and outcomes of collaborations

Published papers reported on outcomes for two cases (not cited to protect confidentiality). Other cases included plans for evaluation supported by an evaluation framework or a logic model. Participants shared a range of perceived impacts and outcomes. Most cases appeared to have achieved multiple outcomes relating to Q-Aims.

Improved outbreak management (Cases 1, 3, 9, 10) and enhanced harm reduction (Case 2) were perceived to have achieved safer care for the population, a condition required for a quality health services system [33] as well as improvements in population health. Quality of services was increased as clients benefited from services offered through PC-PH collaborations (Cases 1, 2, 3, 6). For example:

Definitely PH’s involvement in the 18-month visit did change the way that we deal with the 18-month visits and in general- baby visits. We’ve changed and have become a little bit more creative, more open to new things and whatever can help us do things better and help the parents with their child better. [Case 1 PC-RN].

Improved service delivery models that included program expansion were achieved through shared services, access to information technology, and record keeping redesign (Cases 3, 4 and 10).

The health centre has been doing immunizations for the marginalized through our nursing services for quite some time… What [street outreach] does though is allow for expansion of that. [Case 10 PC-MD]

Participants perceived that there were service improvements related to continuity, reliability and responsiveness. Work processes were enhanced through the development of support networks that enabled access to resources and enhanced communication among partners, thereby improving patient experience:

…whenever we have a new case who is infectious, we case conference and include all of the relevant players […] so that we’re all on the same page. [Case 9 PH-PHN]

Timeliness of services was enhanced through reduced wait times (Case 4) and increased person-centred care (Case 6 and 7). Participants reported improved relationships between clients and providers (Case 9).

From a population health perspective, 8 of 10 cases reported improved access to services for marginalized populations to address health inequities (Cases 1, 2, and 5 to 10). This was achieved through inter-agency referral and communication, joint programming to improve service efficiencies, and advancing outreach activities:

But that group of marginalized people would not have been immunized if [street outreach] and PH did not have that relationship. They would have had to wait to get into their family doctor. And they wouldn’t have gotten in because they wouldn’t have necessarily had a family doctor. [Case 10 PH-Other]

Participants in Cases 5 and 8 reported policy impacts at a municipal/regional level.

It did affect public policy in terms of getting [the district] to look at the development of walking trails... [Case 5 PH-PHN].

Other collaborations paved the way for policy change.

And that’s why we were able to champion the H1N1 flu vaccine for that population specifically and just do it. Which is basically changing public policy because we just did it, and it was against what we were being told to do at the provincial level. So, I think some of that public policy stuff, this partnership has enhanced it. [Case 10 PH-Other]

Other population health impacts included: increased immunization rates and enhanced ability to respond to epidemics (Cases 7 and 10), enhanced awareness of community health problems (Cases 6 and 9), reduced tobacco use (Case 2), and a shift to a population focus (Cases 7 and 9).

A few cases reported perceived cost-reducing efficiencies through shared programming, record keeping, or delivery of vaccines to PC offices based on use (Cases 3, 4). Costs savings were realized through better resource allocation, reduced vaccine wastage, resource sharing (e.g., IT systems), and in some cases, reduced workloads by avoiding duplication:

So, we decided that, why can’t we have Public Health go with the family practice nurses and nurse practitioners and run a clinic in the primary healthcare clinics across [the county]? So, we organized that last year. […]. It had bumps but for the most part, it reduced the need for additional resources. [Case 3 Both-Other].

In relation to the provider experience, staff knowledge and skills increased including a stronger understanding of partner roles and functions, valuing of roles, and improvements in evidence-informed practice:

PH has recognized our connection and our relationship to that community […] ‘Okay, how do we work with you since you’re going to do this?’ What can we do to make your job easier but also to increase the components around prevention, treatment and care in the community? [Case 10 PC-RN]

There were positive impacts as a result of relationship building, such as improved accountability:

… When you meet on a front-line level, I think there's a different accountability.... […] there is an accountability piece that happens there because we've entered into this relationship and we've agreed that we will service these women in a very distinct way… [Case 6 PC/PH-Other]

There also were positive spin offs from other agencies’ contributions to collaborations:

So, the NP and the physician, they were forced to deal with a lot of non-medical PC issues to get people there. So, I think their scope really expanded because they could work with the [NGO] where advocacy is one of their main roles and learn from them. [Case 6 PC/PH-Other].

Drawbacks and benefits of collaboration

Multiple benefits from collaboration were perceived as it relates to patient experience:

It’s quite a powerful synergy when you have PC and PH rubbing shoulders together. … if there’s the interchange of ideas, there’s also a much better experience for the client to be able to access all of those things […] in a much more powerful way. [Case 9 PC/PH-MD]

In terms of provider experience job satisfaction was improved in some situations despite a lack of compensation for added responsibilities:

… financially [collaboration is] a disadvantage […]. I think we’d do it anyways just for our own personal satisfaction. [Case 1 PC-RN]

Participants reported few drawbacks. A few perceived collaborations to benefit some partners more than others, particularly if collaborations appeared to divert resources away from valued services or if collaborations added to busy PC or PH workloads (i.e., provider experience).

In all cases, the majority of PSAT respondents reported that collaboration “benefits exceeded the drawbacks” or “greatly exceeded the drawbacks” (Fig. 1). The majority attributed benefits of collaboration to (Table 4): the development of valuable relationships (provider experience), enhanced ability to meet the needs of my constituency or clients (patient experience), ability to make a greater impact than I could have on my own (patient/provider experience), ability to make a contribution to the community (population health/patient experience), and enhanced ability to address important issues (population health/provider experience). Two items that helped explain drawbacks were: time diverted from other activities (patient/provider experience), and frustration or aggravation (provider experience) (Table 5).

Benefits versus drawbacks of participation

PSAT satisfaction (provider experience) responses indicated that participants, other than rural health promotion (Case 7), were generally satisfied (completely or mostly) with: a) working together (range 33–100% of participants per case; average 74.5%), b) role (range 59–88%; average 75%), c) influence (range 50–100%; average 74%), and d) plans (range 50–100%; average 74%). In Case 7, general satisfaction scores ranged from 9 to 40 and 20% of participants indicated that drawbacks exceeded benefits. These results may explain some of the high staff turnover in this collaboration.

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