Objective To describe family physicians' experiences of administrative burden in practice. Design Qualitative study using constructivist grounded theory. Setting Ontario. Participants Family physicians. Method In-depth virtual interviews with family physicians practising in Ontario who completed postgraduate training between 2017 and 2022. Main findings A total of 36 family physicians were interviewed. Without external prompting, all participants raised the issue of administrative burden, offering specific contextual factors contributing to their administrative burden. These included volume of paperwork, inbox management, and lack of compensation for the hours of administrative tasks performed. In addition to these contextual factors, 2 main themes were identified: the first revealed the impact of administrative burden on both the time available for patient care and physicians' well-being. This latter issue was exacerbated by deteriorating relationships with specialist colleagues, contributing to family physicians' administrative burden and burnout. A lack of exposure to the volume of administrative duties during training added to this issue. The second theme described participants' personal strategies (eg, creating flex time, setting boundaries) and system solutions (eg, need for compensation for administrative time, funding to increase clinic staff, and interventions by regulatory bodies) to address administrative burden. Conclusion Administrative burden negatively impacts physician well-being and reduces time for direct patient care. These findings highlight2 new sources contributing to administrative burden: deteriorating relationships between family physicians and specialist colleagues and a lack of exposure to managing administrative responsibilities during medical training. Study findings provide personal strategies and system solutions to guide practitioners, policy-makers, and educators.

OBJECTIVE:To describe family physicians' experiences of administrative burden in practice. DESIGN:Qualitative study using constructivist grounded theory. SETTING:Ontario. PARTICIPANTS:Family physicians. METHOD:In-depth virtual interviews with family physicians practising in Ontario who completed postgraduate training between 2017 and 2022. MAIN FINDINGS:A total of 36 family physicians were interviewed. Without external prompting, all participants raised the issue of administrative burden, offering specific contextual factors contributing to their administrative burden. These included volume of paperwork, inbox management, and lack of compensation for the hours of administrative tasks performed. In addition to these contextual factors, 2 main themes were identified: the first revealed the impact of administrative burden on both the time available for patient care and physicians' well-being. This latter issue was exacerbated by deteriorating relationships with specialist colleagues, contributing to family physicians' administrative burden and burnout. A lack of exposure to the volume of administrative duties during training added to this issue. The second theme described participants' personal strategies (eg, creating flex time, setting boundaries) and system solutions (eg, need for compensation for administrative time, funding to increase clinic staff, and interventions by regulatory bodies) to address administrative burden. CONCLUSION:Administrative burden negatively impacts physician well-being and reduces time for direct patient care. These findings highlight 2 new sources contributing to administrative burden: deteriorating relationships between family physicians and specialist colleagues and a lack of exposure to managing administrative responsibilities during medical training. Study findings provide personal strategies and system solutions to guide practitioners, policy-makers, and educators.

Context: There is a crisis in Family Medicine with a critical decline in family physicians practicing comprehensive care. This shortage threatens the foundation of primary care which is the core of a high functioning health care system. Objective: To explore early career family physicians' (FPs) decisionmaking process in their choice to practice comprehensive care. Study Design and Analysis: Grounded theory study using in-depth interviews via Zoom, with individual and team analysis. Setting: FP practices in Ontario, Canada. Population Studied: 38 family physicians practicing in Ontario, who completed their residency training within the last 5 years. Results: Participants' stories revealed their journey in establishing a comprehensive care practice. Many participants began this journey doing locums. Reasons for locuming included: 'testing the waters' by experiencing different practice types; flexibility of hours worked with no responsibility for practice management and not being ready to commit to a patient roster. The next juncture in their journey was deciding to commit to a practice (either through purchasing a practice or taking over a practice of a retiring physician). For many participants, this settling into providing patient care from 'cradle to grave' took on a new definition, and was described as a 'hybrid model'. They had much smaller patient rosters, often working 3 days per week providing officebased comprehensive care and 2 days a week practicing in a specific area of interest (e.g. women's health, dermatology, hospitalist). The hybrid model of practice offered variety and for some mitigated burnout. Like any traveller on a journey, participants faced many contextual challenges that threatened the practice of comprehensive care. These included: the burden of administrative tasks; the deteriorating specialist-family physician relationship; lack of access to team-based models; inadequate remuneration; and a pervasive feeling that Family Medicine is undervalued, leaving them feeling 'cynical and burned out'. Conclusions: Findings reveal how the definition and practice of comprehensive care is currently under construction influenced by both individual needs and expectations of early career FPs as well as the current context in which they practice. The findings have implications for educators in curriculum planning and for health workforce planning as this 'hybrid model' of delivering comprehensive care evolves in Family Medicine.

Context: Several months before the arrival of COVID-19, the province of Ontario rolled out a new structure of integrated health care delivery known as Ontario Health Teams (OHTs). Key to the development of OHTs was the intentional engagement of family physicians (FPs). Objective: This ongoing study initially explored the role of FP leaders and their role as champions in engaging community-based FPs in OHTs. After 3 years of study, we can now describe the evolution of the FP leaders’ roles and activities. Study Design and Analysis: Descriptive qualitative study using individual interviews. An iterative and interpretive process was conducted with individual and team analysis to identify overarching themes. Setting: Regional health care organizations in Ontario, Canada. Population Studied: A purposive sample of 35 primary care leaders (48 interviews in total) engaged in health system change from across Ontario, from January 2020 – April 2022. Results: Over the last 3 years, an evolution has been occurring as FP leaders transition from being champions who push out ideas to leaders who co-create and enact ideas. Their initial motivation to serve as leaders was to advocate for their patients and the discipline of Family Medicine while being committed to making significant changes in how health care is provided. While these basic principles remain, the COVID-19 pandemic required that they shift their priorities and activities. This included planning the procurement of PPE and organizing health human resources for assessment and vaccination centres. In addition, many FP leaders were called upon to contribute to pandemic response planning organizations, locally and provincially. Collectively, they brought a strong voice for primary care to these tables, often serving as brokers and bridge-builders across multiple sectors. For some, responsibility of the work and volume became exhausting, raising concerns about potential burnout. The recognition of the need to develop sustainable infrastructure to enlarge the pool of FP leaders and to maintain current leaders was strongly emphasized. Conclusion: These findings provide a unique perspective on the evolution of FP leadership in health system change and the contextual factors that are influencing this transition.

Context: Family physician participation is increasing in health system design and implementation in Ontario. Therefore, it is important to determine a definition of meaningful involvement and explore the activities and processes that constitute meaningful involvement. Objective: The purpose of the study was to elicit primary healthcare leaders' definition of meaningful involvement in the conception, design and delivery of integrated care planning and implementation as well as to identify various means to measure meaningful involvement. Study Design and Analysis: Grounded theory study using in-depth interviews via Zoom, with individual and team analysis. Setting: Ontario, Canada. Population Studied: twenty-two primary healthcare leaders (family physicians and decision-makers) affiliated with Ontario Health Teams (OHTs). Results: Participants found it challenging to provide a clear definition of 'meaningful involvement'. However, a few participants did offer definitions that consisted of different levels of involvement. These ranged from being aware/informed; to participating in some activities; to more active involvement, including leading activities/being at the decision-making table; and some participants highlighted another level of involvement -- using the clinical services/being integrated into the clinical pathway within the OHT. All participants offered ideas about how to measure/assess meaningful involvement of family physicians while recognizing the challenges inherent in creating appropriate measures. Their suggestions ranged from relatively easy items to measure, such as attendance at meetings and counting opened emails to a more comprehensive set of activities such as involvement in the co-design/evaluation of programs. Participants believed that involving family physicians in the co-design of program implementation activities fosters ownership and empowerment, leading to improved health care delivery in Ontario. Participants articulated that the foundation for meaningful involvement of family physicians in health system change is relationship building: trust and respect are paramount. Conclusions: This study illuminates the challenges in defining and measuring meaningful involvement of family physicians in health system design and implementation. These findings are assisting the Ontario Ministry of Health as they continue to support family physicians' involvement in the conception, design and delivery of program implementation activities.

Context: COVID-19 exacerbated the shortage of family physicians providing comprehensive care in Ontario. For family physicians in their first years of practice, they were faced with either receiving their family medicine training during the pandemic or, equally challenging, beginning their practice during COVID-19. Objective: To explore the impact of COVID-19 on the training and practice of early career family physicians (FPs), and the influence on their decision-making process to practice comprehensive care. Study Design and Analysis: Grounded theory study using in-depth interviews via Zoom, with individual and team analysis. Setting: FP practices in Ontario, Canada. Population Studied: 38 family physicians practicing in Ontario, who completed their residency training within the last 5 years. Results: Family Medicine (FM) residents experienced varying levels of COVID19-related disruptions, including an abrupt change to virtual care and fewer in-person community and clinic opportunities during their training. The impact of COVID-19 on participants included feeling isolated from other residents and staff and having less exposure to in-person procedures (e.g. minor procedures, OB) which made them less confident to perform these skills on graduation. Conversely, some described an increased skillset in acute medicine through redeployment or additional hospital-based rotations. Concurrently, new graduates in the COVID-era experienced challenges in their workforce entry, often during locums where there was reliance on virtual care, less on-site support and adapting to a disrupted system. They were simultaneously exposed to focussed FM opportunities that were part of a larger call to action such as vaccine clinics and assessment centres which they noted to be relatively highly remunerated, lower stress, and often a positive environment in terms of appreciative patients and socialization with colleagues. Conclusions: Findings reveal the impact of COVID-19 on the training and early career experiences of new graduates at a critical juncture in professional identity formation. Disruptions in the health system presented challenges to comprehensive FM care and offered attractive focussed practice choices. The findings have implications for educators and health workforce planning as the impact of COVID-19 on early career physicians needs further exploration and remedy to ensure comprehensive FM remains a viable choice going forward.

PURPOSE:To understand staff and health care providers' views on potential use of artificial intelligence (AI)-driven tools to help care for patients within a primary care setting.METHODS:We conducted a qualitative descriptive study using individual semistructured interviews. As part of province-wide Learning Health Organization, Community Health Centres (CHCs) are a community-governed, team-based delivery model providing primary care for people who experience marginalization in Ontario, Canada. CHC health care providers and staff were invited to participate. Interviews were audio-recorded and transcribed verbatim. We performed a thematic analysis using a team approach.RESULTS:We interviewed 27 participants across 6 CHCs. Participants lacked in-depth knowledge about AI. Trust was essential to acceptance of AI; people need to be receptive to using AI and feel confident that the information is accurate. We identified internal influences of AI acceptance, including ease of use and complementing clinical judgment rather than replacing it. External influences included privacy, liability, and financial considerations. Participants felt AI could improve patient care and help prevent burnout for providers; however, there were concerns about the impact on the patient-provider relationship.CONCLUSIONS:The information gained in this study can be used for future research, development, and integration of AI technology.

Abstract Rationale, Aims and Objectives A learning health system model can be used to efficiently evaluate and incorporate evidence‐based care into practice. However, there is a paucity of evidence describing key organizational attributes needed to ensure a successful learning health system within primary care. We interviewed stakeholders for a primary care learning health system in Ontario, Canada (the Alliance for Healthier Communities) to identify strengths and areas for improvement. Method We conducted a qualitative descriptive study using individual semistructured interviews with Alliance stakeholders between December 2019 and March 2020. The Alliance delivers community‐governed primary healthcare through 109 organizations including Community Health Centres (CHCs). All CHC staff within the Alliance were invited to participate. Interviews were audio‐recorded and transcribed verbatim. We performed a thematic analysis using a team approach. Results We interviewed 29 participants across six CHCs, including Executive Directors, managers, healthcare providers and data support staff. We observed three foundational elements necessary for a successful learning health system within primary care: shared organizational goals and culture, data quality and resources. Building on this foundation, people are needed to drive the learning health system, and this is conditional on their level of engagement. The main factors motivating staff member's engagement with the learning health system included their drive to help improve patient care, focusing on initiatives of personal interest and understanding the purpose of different initiatives. Areas for improvement were identified such as the ability to extract and use data to inform changes in real‐time, better engagement and protected time for providers to do improvement work, and more staff dedicated to data extraction and analysis. Conclusions We identified key components needed to establish a learning health system in primary care. Similar primary care organizations in Canada and elsewhere can use these insights to guide their development as learning health systems.

Context: Several months before the arrival of COVID-19, the province of Ontario began to roll out a new structure of integrated health care delivery. In response, after decades of lacking a cohesive structure, family physicians began to spontaneously form grassroots organizations in order to be engaged in the process of reform. Objective: This study describes the formation and structure of these organizations, and the impact of the COVID-19 pandemic on their development. Study Design: In accordance with Grounded Theory methodology, individual interviews were analyzed, including a constant comparative approach. Setting: Regional health care organizations in Ontario, Canada. Population Studied: A purposive sample of twenty primary care leaders engaged in health system change from across Ontario. Results: While these grassroots organizations assumed different names (e.g., alliance, coalition, collaborative), and varied in their structure (e.g. high/low governance), they shared a common vision of having a strong and unified voice in health system change. Prior to the pandemic, these organizations served as a vehicle to discuss shared “pain points” and seek common solutions to local challenges. The declaration of the pandemic mobilized these organizations to respond in several ways. The most important feature was their capacity to rapidly respond at a local level to the pandemic crisis. With lines of communication already established and a foundation of trusting relationships, these organizations acted on requests for PPE, staffing of assessment centres, and created respiratory assessment centres. Participants often noted how the pandemic was a galvanizing agent in the development and engagement of the membership within their organization. Conclusion: Study findings suggest that, while these family medicine organizations came together in response to health care reform in order to create a common voice, the pandemic accelerated not only their value but also the importance of remaining grounded in the needs of their local communities.

Context: Health systems are in a state of constant change. In the province of Ontario, Canada, a new initiative called Ontario Health Teams (OHTs) was introduced in 2019 to create an integrated health care system, bringing together various sectors (e.g. primary care, community care, specialists, and hospitals). These OHTs were gradually rolled out across the province between 2019 to the present. Objective: This study presents the impact of the COVID-19 pandemic on the development of OHTs through the lens of primary care. Study Design: In accordance with Grounded Theory methodology, individual interviews were analyzed, including a constant comparative approach. Setting: Regional health care organizations in Ontario, Canada. Population Studied: A purposive sample of twenty primary care leaders engaged in health system change from across Ontario with extensive knowledge of OHTS. Results: The participants described, from the perspective of primary care, how the OHTs responded in three different ways to the pandemic. Some OHTs were forced to put further development on hold, as they pivoted to COVID concerns (e.g. long-term care facilities, PPE). Others described losing momentum temporarily, but then getting back on track and evolving more quickly. Still others explained how their OHT activities never faltered, and indeed, the pandemic rapidly accelerated their development, describing COVID-19 as a ‘silver lining’. A common experience articulated by participants was the breaking down of organizational silos as the pandemic necessitated all sectors to work together. The burgeoning collaborative relationships being established through OHT structures were viewed as facilitating this coming together, serving as a “proof of concept” of the “what and how” of OHTs. Conclusions: The COVID-19 pandemic has disrupted so many aspects of health care across the globe but for the OHT’s, an important health system innovation, it has served as an opportunity to examine what worked well and what could have been executed more effectively. Going forward the OHT’s can build on the “lessons learned”.

The purpose of this qualitative study was to explore how team members experience and enact interprofessional teamwork in primary health care (PHC). Fifty-three participants (from eight teams), members of the Association of Family Health Teams of Ontario (AFHTO), were interviewed; interviews were audiotaped and transcribed verbatim. The data analyses used an iterative process with individual and team analysis. Findings revealed components that comprise the foundation and pillars of collaborative interprofessional teamwork in PHC. First, participants described a shared philosophsy of teamwork with six elements: values, vision, and mission; collaboration; communication; trust; respect and team members that ‘fit.’ Second, findings revealed three ‘pillars.’ The first pillar, leadership, included the elements of specific leadership attributes, such as leaders encouraging teamwork, mitigating conflict, and facilitating change. In the second pillar, participants described three elements of team building: formal and informal team building activities plus how these activities benefited both the team and patient care. The last pillar, optimizing scope of practice, included the elements of recognizing, appreciating, utilizing, and expanding team members’ scope of practice. While each component and their concomitant elements can be enacted individually, collectively applying all elements produces collaborative interprofessional teamwork in primary health care.

Objective To extend our understanding of how primary health care team members characterize the effects of location on team functioning. Design Qualitative study using grounded theory methodology, with in-depth analysis of data concerning the rote of physical space in teamwork. Setting Family health teams in Ontario. Participants A total of 110 team members from 20 family health teams in Ontario. Methods Individual semistructured interviews were conducted. Interviews were audiorecorded and transcribed verbatim. Individual and group coding followed grounded theory processes of open, axial, and selective coding. Immersion in interview and field note data facilitated crystallization. Main findings Across sites, regardless of their physical space, team members commented spontaneously about the role of space in team functioning. An overarching theme of a "sense of place" developed from data analysis. A sense of place could be established through co-location (being in the same physical space), the allocation of team members' working spaces, coming together, and having a shared vision. Physical space often operated as a key facilitator or considerable barrier to creating a sense of place; however, some teams with suboptimal physical space functioned as highly integrated teams, creating a sense of place through various means. Conclusion Many interprofessional health care teams cannot physically change less-than-optimal spaces. However, teams can thrive and create a sense of place through various means, some of which relate to actual physical space, and some of which relate to promoting common activities and a shared vision-factors that are effective for team building in general. When there are economic limitations, as well as structural constraints, then it is essential that creating a sense of place be a priority. Future research should consider this lens as a means for expanding the discussion and possible solutions around traditional space issues.

Objective To use data from a workshop in which various representatives from departments of family medicine (DFMs) aimed to identify strategies to increase research activity, particularly among clinical faculty members. Design Descriptive qualitative study using data from a workshop in which participants role-played (ie, as clinician-teachers, department chairs, and mentors) and, white in the role-playing scenario, were asked to imagine strategies that would encourage the clinical faculty members to engage in research. Setting The 2014 North American Primary Care Research Group Annual Meeting in New York City, NY. Participants Thirty-two workshop participants who belonged to DFMs and other academic primary care organizations: 18 from Canada, 11 from the United States, 2 from Australia, and 1 from the Netherlands. Methods Facilitators recorded the strategies at the workshop. Strategies were organized into themes and vetted by facilitators to ensure that they adequately represented the data. Finalized themes were compared and integrated across scenarios. Main findings Participants enthusiastically and productively engaged in the role-playing scenarios. The themes that emerged from the workshop discussions indicated that in order to increase clinician-teacher engagement in research, the following factors needed to be attended to: gaining confidence in conducting research; finding research topics that have personal relevance; presenting clarity of expectations; fostering collaborative relationships; using a tailored approach; providing resources, structures, and processes; and having leadership and vision. Finally, it was important to recognize these efforts in the context of the existing research environment of the DFM and the various responsibilities of clinician-teachers. Conclusion The analysis of data arising from this simulation workshop elucidated practical strategies for building and sustaining research in DFMs. There is a clear indication that one size does not fit all with respect to strategies for building a research culture in a DFM; the authors' recommendations guide departments to tailor strategies to their unique context.

BACKGROUND:Patient-centred care, access to care, and continuity of and coordination of care are core processes in primary health care delivery. Our objective was to evaluate how these processes are enacted by 1 primary care model, Family Health Teams, in Ontario.METHODS:Our study used grounded theory methodology to examine these 4 processes of care from the perspective of health care providers. Twenty Family Health Team practice sites in Ontario were selected to represent maximum variation (e.g., location, year of Family Health Team approval). Semi-structured interviews were conducted with each participant. A constant comparative approach was used to analyze the data.RESULTS:Our final sample population involved 110 participants from 20 Family Health Teams. Participants described how their Family Health Team strived to provide patient-centred care, to ensure access, and to pursue continuity and coordination in their delivery of care. Patient-centred care was provided through a variety of means forging the links among the other processes of care. Participants from all teams articulated a commitment to timely access, spontaneously expressing the importance of access to mental health services. Continuity of care was linked to both access and patient-centred care. Coordination of care by the team was perceived to reduce unnecessary walk-in clinic and emergency department visits, and facilitated a smoother transition from hospital to home.INTERPRETATION:These 4 processes of patient care were inextricably linked. Patient-centred care was the focal point, and these processes in turn served to enhance the delivery of patient-centred care.

IntroductionHealth sector management is increasingly complex as new health technologies, treatments, and innovative service delivery strategies are developed. Many of these innovations are implemented prematurely, or fail to be implemented at scale, resulting in substantial wasted resources. MethodsA scoping review was conducted to identify articles that described the scale up process conceptually or that described an instance in which a healthcare innovation was scaled up. We define scale up as the expansion and extension of delivery or access to an innovation for all end users in a jurisdiction who will benefit from it.ResultsSixty nine articles were eligible for review. Frequently described stages in the innovation process and contextual issues that influence progress through each stage were mapped. 16 stages were identified: 12 deliberation and 4 action stages. Included papers suggest that innovations progress through stages of maturity and the uptake of innovation depends on the innovation aligning with the interests of 3 critical stakeholder groups (innovators, end users and the decision makers) and is also influenced by 3 broader contexts (social and physical environment, the health system, and the regulatory, political and economic environment). The 16 stages form the rows of the Nose to Tail Tool (NTT) grid and the 6 contingency factors form columns. The resulting stage-by-issue grid consists of 72 cells, each populated with cell-specific questions, prompts and considerations from the reviewed literature.ConclusionWe offer a tool that helps stakeholders identify the stage of maturity of their innovation, helps facilitate deliberative discussions on the key considerations for each major stakeholder group and the major contextual barriers that the innovation faces. We believe the NTT will help to identify potential problems that the innovation will face and facilitates early modification, before large investments are made in a potentially flawed solution.

This article describes the triangulation of qualitative dimensions, reflecting high functioning teams, with the results of standardized teamwork measures. The study used a mixed methods design using qualitative and quantitative approaches to assess teamwork in 19 Family Health Teams in Ontario, Canada. This article describes dimensions from the qualitative phase using grounded theory to explore the issues and challenges to teamwork. Two quantitative measures were used in the study, the Team Climate Inventory (TCI) and the Providing Effective Resources and Knowledge (PERK) scale. For the triangulation analysis, the mean scores of these measures were compared with the qualitatively derived ratings for the dimensions. The final sample for the qualitative component was 107 participants. The qualitative analysis identified 9 dimensions related to high team functioning such as common philosophy, scope of practice, conflict resolution, change management, leadership, and team evolution. From these dimensions, teams were categorized numerically as high, moderate, or low functioning. Three hundred seventeen team members completed the survey measures. Mean site scores for the TCI and PERK were 3.87 and 3.88, respectively (of 5). The TCI was associated will all dimensions except for team location, space allocation, and executive director leadership. The PERK was associated with all dimensions except team location. Data triangulation provided qualitative and quantitative evidence of what constitutes teamwork. Leadership was pivotal in forging a common philosophy and encouraging team collaboration. Teams used conflict resolution strategies and adapted to the changes they encountered. These dimensions advanced the team's evolution toward a high functioning team.

How can we make research findings more relevant to our patient populations in primary care? Groups of experts review the evidence to make clinical practice guidelines. This randomized controlled trial (RCT) evidence is limited by strict inclusion criteria that produce idealized patient populations