Throughout Canada, healthcare systems are challenged by population growth, aging, and physician retirement and relocation. These, among other factors, have added demands to and limited the capacity of the healthcare system.
Such challenges require a combination of initiatives, including community-driven efforts to first understand and then respond to local and regional needs. In British Columbia, the Ministry of Health and Doctors of BC worked in partnership through the General Practice Services Committee (GPSC), to foster community action of this sort, through a three-year initiative named A GP for Me. Launched in 2013, A GP for Me had three goals:
- Confirm and strengthen the continuous doctor and patient relationship, including better support for the needs of vulnerable patients.
- Increase the capacity of the primary health care system.
- Enable patients who want a family doctor to find one.
Funding for A GP for Me was provided in two ways: the creation of incentive fees to facilitate practice-level change with physicians; and investments in projects delivered by more than thirty Divisions of Family Practice, groups of family physicians in over 230 communities across British Columbia.
At the heart of it, A GP for Me was truly a community-driven, broad undertaking to foster innovation, quality and continuity in patient access and care.
The Task: Undertaking a Provincial Evaluation of A GP for Me
Evaluating an initiative like that of A GP for Me is complicated. A few of the twists and turns of this endeavour centred on the following.
Relating Results: A GP for Me was one of many efforts in British Columbia to further health care system transformation. Additionally, divisions of family practice had been formed around the province, providing an alternative way for family physicians to collaborate with health authorities and other partners to identify and address local healthcare challenges. Over the course of A GP for Me, about 150 projects were started by divisions, each furthering its own form of innovation. This made the direct attribution and summary of results to A GP for Me challenging.
Harnessing Efforts: The purpose of the provincial evaluation was to not only gain an understanding of the effectiveness of A GP for Me from the experiences of those involved but also to share lessons learned from innovations that seek to enhance the quality of care.
In addition to the provincial evaluation, divisions were also completing assessments of the effectiveness of supported projects, to inform their own learning and innovation. The provincial evaluation had to harness these local efforts to allow for an integration of findings, while also not obstructing the unique work that was proceeding.
Dealing with Unknowns: In 2015, a substantial Provincial Evaluation Plan was prepared for A GP for Me with the involvement of staff from the Doctors of BC and the Ministry of Health, a GPSC Evaluation Working Group, contracted specialists, a Divisions Reference Group, and evaluators hired by various divisions.
Following the completion of this Provincial Evaluation Plan, and by the time the provincial evaluation commenced, it became apparent that the awareness of stated outcomes and indicators of performance for A GP for Me had since diminished such that partners were challenging concepts, describing intentions and using measures in a variety of disparate ways. This complicated the ability to draw comparisons and roll-up findings across the province. In addition, as the provincial evaluation progressed, it became clear that baseline data was not always available for some of the indicators and planned data sources (e.g. a Core Provincial Patient Survey) would not be obtained in time.
The Answer: A Collaborative and Adaptive Approach to the Evaluation
The success of the provincial evaluation of A GP for Me was founded on the following key principles that guided the work of what was a hybrid evaluation team, made up of staff from the Doctors of BC as the contracting authority and MNPLLP as the contracted evaluator.
Collaboration: Members of the Doctors of BC team and the MNP team worked closely together, such that the provincial evaluation was a truly collaborative undertaking. This extended beyond frequent, joint check-in meetings to include the co-facilitation of consultations as well as the assigning of work across the combined teams. It was also critical to coordinate with the work of other evaluators, be it the ones engaged by divisions or those working on components of the Provincial Evaluation Plan.
Integration: The provincial evaluation had to integrate the foundational work of the Divisions of Family Practice and that of several other external evaluators, as well as administrative data from the Ministry of Health. With the divisions, a tiered, thematic analysis was carried out of thirty “Final Evaluation and Project Implementation Close-Out Reports” in the form of a high-level summary, division highlights, and direct report extracts.
In addition to these close-out reports and what was referenced above, there were the results of surveys (e.g. of family physicians, with the GPSC, and the Canadian Community Health Survey), interviews with health authorities and the BC Ministry of Health, and facilitated focus group sessions.
Adaptation: Allowances had to be made for adaptations to the Provincial Evaluation Plan to address gained insight, respond to any gaps in information, and ensure key perspectives were accounted for.
It was also critical to follow an iterative approach to validating early findings and interpretations. This took the form of a staged confirmation of the findings with a variety of stakeholders, covering the various components of the analyses (e.g., interpretations of the administrative data).
The Takeaways: Reflecting on the Experiences of the Evaluation
Just as A GP for Me has illustrated that there is not one solution to address the complex challenges of BC’s health care system, the provincial evaluation highlighted opportunities for future practice.
There are clear benefits to be gained from adopting hybrid evaluation teams, bringing together experienced staff and third-party contractors. Yet, it is important to also keep in mind the maintenance of harmony and balance in teams, be it with respect to size, well-defined and agreed upon roles, and contributed areas expertise.
Having a well-thought-out plan, or framework, for an evaluation is another factor of success. The value of this planning though is nicely summed up by Voltaire, “don’t let the perfect be the enemy of the good.” Ongoing socialization of an evaluation plan and allowing for moments for adaptation along the way should be embraced.
With initiatives that serve to foster innovation, especially across geographic and other communities of interest, there can be a concern of imposing structure, which can come in the form of evaluation. Just as innovation depends on some arrangement for implementation, evaluators need to consider how findings will be combined in a coherent way.
Finally, the pursuit of an all-inclusive, retrospective evaluation may be better replaced with an iterative strategy that allows for the staging of evaluative studies over the course of a major long-term initiative like A GP for Me. In this way, the evaluation approach will naturally evolve with the initiative, and the latter stages of evaluation will yield findings that are informed by refined priorities, strategic direction and focus.
During the final stages of the A GP for Me evaluation, the GPSC was looking forward and updating its strategic direction to include the patient medical home as the foundation of an integrated system of care. The provincial evaluation informed the evolution of the primary health care system in British Columbia, by providing important insights into local healthcare challenges; raising awareness of community-driven innovations that build on the important work of physicians, divisions of family practice, and health authorities; and furthering an environment for conversation on how to continue to improve patient access and care.
Bill Reid, Partner, Advisory Services, MNP and Past President, BC and Yukon Chapter, Canadian Evaluation Society, firstname.lastname@example.org
Jasmina Fatic, Manager, Advisory Services, MNP, and Past Vice President, BC and Yukon Chapter, Canadian Evaluation Society, email@example.com
Petra Lolic, Executive Coordinator, GPSC, Doctors of BC, firstname.lastname@example.org