Examining the extent and factors associated with interprofessional teamwork in primary care settings

ABSTRACT

Despite growing emphasis on adopting team-based models of primary care to facilitate patient access to a diverse range of care providers, our understanding of team functioning within primary care teams remains limited. This study examined interprofessional teamwork within primary care practices (Family Health Teams [FHT] and Community Health Centers – [CHC]) in Ontario and explored team-level and organizational factors associated with interprofessional teamwork. Interprofessional teamwork was measured using the Collaborative Practice Assessment Tool (CPAT), which was completed by providers in each participating team. The CPAT responses of 988 providers representing on average 12 professions (sd = 2.1) across 66 teams (44 FHTs and 22 CHCs) were included in the analysis. The average CPAT score was 46.6 (sd = 2.5). CHCs had significantly higher CPAT scores than FHTs (m_diff = 1.7, p = .02). Using diverse communication mechanisms to share information, increasing quality improvement capacities, and age of practice, had a statistically significant positive association with CPAT scores. Increasing team size, using centralized administrative processes, a high level of information exchange, and having a mixed governance board were significantly negatively associated with CPAT score. Findings illustrate factors associated with interprofessional teamwork and offer insight into the comparative performance of two team-based primary care models in Ontario.

KEYWORDS:

• Primary care
• interprofessional
• teamwork
• organizational factors

Introduction

The adoption of team-based approaches to the delivery of primary care has been a core component of health system reform in Canada (Hutchison et al., 2011; Peckham et al., 2018) and internationally for the past decade (Schottenfeld et al., 2016; Wagner et al., 2017). Access to team-based primary care is associated with improvements in clinical outcomes (Gocan et al., 2014; Manns et al., 2012; Mulvale et al., 2009), better patient experience (Morgan et al., 2020), and reductions in healthcare utilization (Manns et al., 2012; Association of Family Health Teams of Ontario, 2015b; Carter et al., 2016; Riverin et al., 2017; Strumpf et al., 2017).

The inclusion of providers from different training backgrounds is intended to enable practices to offer a wide range of services extending across health and social sectors in a coordinated and cohesive manner (Starfield et al., 2005). Team-based primary care is driven by interprofessional teamwork, which involves blending the individual and shared knowledge and skills of team members from different professions to synergistically inform the provision of care while retaining a focus on patient-centered goals and values (Health Canada, 2010; Samuelson et al., 2012; Reeves et al., 2017). Interprofessional teamwork entails collective action that is rooted in respecting, trusting, and valuing the unique expertise that healthcare professionals from different training backgrounds contribute to patient care (D’Amour et al., 2005). It is driven by shared responsibility and accountability between providers to deliver a continuous, comprehensive, and coordinated continuum of care (Kodner, 2009; Valentijn et al., 2013). The extent to which team members from different professions are able to work together in a cohesive and coordinated manner plays a critical role in the quality of care that teams may deliver (Reeves et al., 2017, 2013).

The foundational attributes of interprofessional teamwork within primary care settings broadly include: 1) the adoption of a shared set of goals and a common mandate to guide collaboration efforts (Cashman et al., 2004; Poochikian-Sarkissian et al., 2008; Xyrichis & Lowton, 2008; Baxter & Markle-Reid, 2009; Van Dongen et al., 2017), 2) communication between providers that facilitates shared care (Bokhour, 2006; E. A. Henneman, 1995; S. S. Morgan et al., 2015; Poochikian-Sarkissian et al., 2008; Shaw et al., 2005; Xyrichis & Lowton, 2008), 3) the presence of trusting relationships and mutual respect between team members (Cashman et al., 2004; Jackson, 2008; McDonald et al., 2012), 4) interdependency between providers that is grounded in an understanding of each member’s role and unique contribution (Nancarrow et al., 2013; Reeves et al., 2010; Xyrichis & Ream, 2008), 5) shared power and leadership support for interprofessional teamwork (Goldman et al., 2010; Mulvale et al., 2016; Orchard & Rykhoff, 2015), 6) family and patient inclusion through active engagement around care planning and shared decision-making (Boult & Wieland, 2010; Légare et al., 2011; Suter et al., 2009); and, 7) the participation of all team members in a collaborative process to ensure alignment between stakeholders and minimize conflict (J. J. Brown et al., 2011; Chong et al., 2013; D’Amour et al., 2005).

However, a diverse range of professionals working together to share care responsibilities can present challenges in terms of differing goals and professional philosophies, gaps in perceptions around scope of practice, and power imbalances between providers from different training backgrounds (Baker et al., 2011; Hall, 2005; Lucas & Bickler, 2000; Reeves et al., 2011; Shaw et al., 2005). Past research has found that primary care teams in particular perform lower on several aspects of team functioning (team participation and a commitment to shared objectives and support for innovation) relative to teams in other healthcare sectors (West & Poulton, 1997; Williams & Laungani, 1999).

Background

The primary care landscape in Ontario has evolved considerably in recent decades involving a shift from traditional fee for service toward more of a blended capitation approach that has involved a strong emphasis on adopting team-based approaches to primary care including ongoing support for Community Health Centers (CHCs) and more recently the introduction of Family Health Teams (FHTs) (Sweetman & Buckley, 2014).

CHCs were introduced in the 1970s, and have a comprehensive mandate to deliver primary care services through interprofessional teams, in addition to health promotion and community programming aimed at addressing the social determinants of health (Association of Ontario’s Community Health Centers, 2016; Collins et al., 2014; Office of the Auditor General of Ontario, 2017). CHCs have historically included a wide range of providers including family physicians, nurses, social workers, physiotherapists, and dieticians (Office of the Auditor General of Ontario, 2017). Physicians in CHCs are salaried since they are considered to be employees of the CHC (Sweetman & Buckley, 2014), and patients are rostered to the CHC, not the individual physician (Office of the Auditor General of Ontario, 2017).

The FHT model was introduced in 2006 as an extension of physician-led capitation-based models. Groups of physicians could establish a FHT by accessing new provincial funding (salary, sessional payment, or contractual agreements) designed to expand service offerings via the addition of providers from a wide range of professions including social workers, dieticians, and pharmacists (Sweetman & Buckley, 2014). In terms of reimbursement, physicians in FHTs offer a broad range of services and receive a blended model of funding, including capitation, fee for service and additional incentives for certain prevention targets (Rosser et al., 2011).

There are 187 FHTs that serve over 3 million Ontarians, and 74 CHCs serving 500,000 patients (about half of this patient population use CHC-based primary care services) (Association of Family Health Teams of Ontario, 2020; Association of Ontario’s Community Health Centers, 2016). Approximately 21% of primary care physicians in the province work in FHTs and CHCs (Health Council of Canada, 2009). In total, an estimated 20% of Ontarians are served by an interprofessional primary care team (Hutchison & Glazier, 2013).

While there are differences between FHTs and CHCs with regard to governance model, funding approaches and scope of organizational mandate, FHTs and CHCs given their team composition are the only interprofessional primary care models in Ontario. Recent studies have found that CHCs are performing better than other primary care models in Ontario on multiple dimensions including healthcare utilization, health promotion, and chronic disease management (Glazier, Zagorski, & Rayner, 2012; Hogg et al., 2009; Russell et al., 2009). Both models reflect many of the core principles of the patient-centered medical home model (Anderson & Olayiwola, 2012; Rosser et al., 2011), and are driven by care teams that are comprised of providers from a wide range of professions (Sweetman & Buckley, 2014).

But despite considerable reform to facilitate a shift toward interprofessional models of primary care delivery, our understanding of the extent and factors associated with interprofessional teamwork in primary care teams remains limited. To date, there is no comprehensive large-scale examination of the extent of interprofessional teamwork involving CHCs and FHTs. This gap in knowledge provided the impetus for this study which sought to assess the extent of interprofessional teamwork within the two team-based primary care models (FHTs and CHCs) in Ontario and explore what team features and organizational characteristics at a practice level are associated with interprofessional teamwork.

Methods

Research design and setting

This study involved a cross-sectional comparison of interprofessional teamwork using a validated survey. The sampling frame for this study was focused on FHTs and CHCs – the two interprofessional team-based primary care models currently operational in Ontario.

Practice recruitment

Recruitment efforts for CHCs were directed through the membership associations for the two primary care models in Ontario – the Alliance for Healthier Communities (Alliance/formerly Association of Ontario Health Centers [AOHC]) and the Association of Family Health Teams of Ontario (AFHTO). An invitation letter with a summary of study objectives and the process to participate, along with an electronic link for CHCs to sign up was sent by the Alliance’s Director of Research to the Executive Directors of all CHCs in Ontario. Interested CHCs could sign up to participate through an electronic link, available through the Hosted in Canada Survey (HICS) platform. Once teams had signed up, the Executive Director of each participating primary care team received a link to complete the Team Profile Survey (TPS), and a link to the CPAT, which they were asked to share with providers and staff in their CHC. For CHCs both the TPS and CPAT were hosted on the HICS platform.

Recruitment for FHTs was undertaken in partnership with AFHTO. AFHTO included an invitation to the research study in their Data To Decisions platform (D2D) – a feedback and performance reporting platform developed by AFHTO to support performance measurement and quality improvement efforts for all FHTs in Ontario (Association of Family Health Teams of Ontario, 2015a). FHTs that were interested in participating were able to sign up and complete the TPS via the D2D, after which a link to the CPAT was sent to each FHT for distribution to providers and staff through the HICS platform. A structured personalized strategy based on principles from the Dillman approach was used to follow up with practices to boost response rates (Thorpe et al., 2009).

Data collection

Collaborative practice assessment tool

The Collaborative Practice Assessment Tool (CPAT) was used to assess the extent of interprofessional teamwork within participating primary care practices. The CPAT offers a team-level assessment of provider perceptions around interprofessional teamwork within organizational boundaries (Schroder et al., 2011). It is considered to be an appropriate instrument to measure interprofessional teamwork (Walters et al., 2016), as it relates to chronic disease management (Bookey-Bassett et al., 2016), which is particularly relevant given the primary care sector’s role in managing individuals with multimorbidity (Boeckxstaens & De Graaf, 2011; Fortin, Bravo et al., 2005; Starfield et al., 2003). The CPAT was chosen over other tools such as the Team Climate Inventory (TCI) and the Modified Index for Interdisciplinary Collaboration, given strong concordance between the key constructs assessed by the CPAT, and core dimensions identified in the literature as foundational components of interprofessional teamwork (Bookey-Bassett et al., 2017, 2016). Unlike other tools, the CPAT includes items pertaining to constructs of shared power and leadership (Elizabeth A Henneman et al., 1995; D’Amour et al., 2005; Suter et al., 2007; Sangaleti et al., 2017;), as well as a separate domain focused on patient and family involvement, both of which have been identified as important features of interprofessional teamwork, especially as it relates to patients with chronic illnesses (Boult & Wieland, 2010; Légare et al., 2011; Dunlay & Chamberlain, 2016). Consistent with its design and past use, the CPAT can help identify areas for improvement as it relates to interprofessional teamwork and inform relevant educational/training interventions, so that practices can use CPAT scores to drive future quality and performance improvement efforts (Schroder et al., 2011; Fisher et al., 2017).

The CPAT has 56 questions across 8 domains including Mission, Meaningful Purpose, Goals; General Relationships; Team Leadership; General Role Responsibilities, Autonomy; Communication and Information Exchange; Community Linkages and Coordination of Care; Decision-making and Conflict Management; and Patient Involvement (Schroder et al., 2011). The CPAT has been used by providers and staff from a wide range of professions including family physicians, nursing staff, nutritionists, social workers, and administrators (Schroder et al., 2011), and different types of healthcare teams, including both CHCs and FHTs (MacPhee et al., 2014; Schroder et al., 2011). Validation tests revealed acceptable levels of reliability with Cronbach alpha scores ranging from 0.73 to 0.90 (Schroder et al., 2011).

To score the CPAT, items within each domain were averaged, and a total measure of interprofessional teamwork was generated by adding the average scores for each domain (Donnelly et al., 2016). Individual provider-level scores were then aggregated to develop a team-level CPAT score. The lowest possible score on the CPAT is an 8, whereas the highest possible score is a 56. The engagement of providers from various training backgrounds and professions involved in primary care delivery was critical in ensuring that the views of providers from diverse roles are reflected in each team’s CPAT score.

Personalized recruitment materials emphasizing the need for representation across professions and repeated contact based on the Dillman method was used to boost response rates (Dillman et al., 2014; Reynolds et al., 2007). Two e-mail reminders (at intervals of two weeks) were sent to the Executive Director of each practice. In some cases, a phone call was also made to the Executive Director to discuss the response rate and determine if the research team could help bolster the response rate in any way. In addition to the CPAT, providers completed 7 brief questions to collect demographic data (i.e., age, sex, and length of employment).

Team profile survey

Information on key organizational characteristics and team features believed to influence interprofessional teamwork within healthcare teams was gathered through a brief Team Profile Survey (TPS), which was completed by the lead managing professional (typically the Executive Director) of each practice. Organizational features of interest included the functional aspects of information technology platforms, i.e., electronic tools to support medical decision-making, access to patient registries to enable targeted programming (i.e., screening for risk factors, etc.) (Moore et al., 2012; S. S. Morgan et al., 2015; Tracy et al., 2013), the co-location of providers (Jenkins et al., 2016; Wener & Woodgate, 2016; Xyrichis & Lowton, 2008), governance model (Golden & Kasperski, 2011), access to shared resources such as office spaces (Harris et al., 2016; Lindeke & Block, 1998; S. S. Morgan et al., 2015; Supper et al., 2015), centralization of administrative processes such as referral/intake procedures (Kodner, D & Spreeuwenberg, 2002), information exchange, in terms of the types of information shared between providers and staff such as patient and caregiver goals/preferences and changes in patient health status (Chong et al., 2013; Steihaug et al., 2017; Supper et al., 2015), communication mechanisms (specifically how that information was shared, i.e., via case-based team meetings, ad-hoc exchanges or structured care plans) (Moore et al., 2012; Tracy et al., 2013) as well as quality improvement capacity (i.e., having a formal process for self-assessment and the provision of regular feedback on performance) (O’Toole et al., 2011). Team features considered in the analysis included team size, number of professions represented, roster size, and co-location (Xyrichis & Lowton, 2008).

Data analysis

A total CPAT score for each practice was generated by computing an average across individual provider responses to the CPAT (Donnelly et al., 2016). Bivariate analyses (pearson correlation coefficients (r), analysis of variance (ANOVA), and t-tests) were conducted to explore the relationship between individual variables and CPAT score, and determine which variables should be included in the regression analysis. Multivariate linear regression (including regression diagnostics, multi-collinearity, etc.) was conducted using STATA (Version 15).

Ethical considerations

Ethics approval for this research study was obtained from the Research Ethics Board at the University of Toronto (Protocol ID 33699). From the outset of data collection, considerable efforts were made to ensure that the privacy of participating primary care teams and providers was ensured; all responses to the CPAT were anonymous, and provider-level CPAT responses were aggregated to generate team-level CPAT scores. Participants were unable to view the CPAT scores of colleagues within their primary care team, as well as of those respondents from other participating primary care teams. All data holdings were encrypted, password-protected, and stored on secure servers to protect the identity and confidentiality of participants.

Results

A total of 45 CHCs and 31 FHTs signed up to participate in this study. One CHC was removed since no providers or staff from that CHC completed the CPAT, and three FHTs were also excluded due to low response rates or incomplete data. An additional 6 FHTs declined to participate during the data collection stage. Following exclusions, a total of 44 CHCs and 22 FHTs, which represent about 25% of all CHCs and FHTs in Ontario participated in this study. There were a total of 1039 responses to the CPAT, and 988 responses were included in the final analysis. A summary of descriptive statistics pertaining to the organizational characteristics and team features of participating CHCs and FHTs is available in Table 1 and Table 2 respectively.

Table 1. Organizational characteristics of 66 practices that completed the TPS

Practice Characteristics	n	(%)
Type CHC FHT	44 22	66.7 33.3
Rurality^a Urban Suburban Rural	38 17 11	57.6 25.8 16.7
Governance Community-based board of directors Mixed board of directors Physician-based board of directors	47 12 7	71.2 18.3 10.6
Number of locations 1 (single site) 2 sites ≥ 3 sites	29 14 23	43.9 21.2 34.9
Quality improvement capacity^b Low (≤ 4 initiatives) Medium (>4 and ≤ 6 initiatives) High (>6 initiatives)	20 29 17	30.3 43.9 25.8
Information Technology capabilities^c Low (≤ 7 functions) Medium (8 functions) High (> 8 functions)	21 21 24	31.8 31.8 36.4
Shared resources^d Low (≤ 6 shared resources) Medium (7 shared resources) High (8 shared resources)	18 25 23	27.3 37.9 34.9
Centralized processes^e Low (≤ 5 processes) High (> 5 processes)	29 37	43.9 56.1
Information exchange^f Low (≤ 4 types of information) High (> 4 types of information)	13 53	19.7 80.3
Communication mechanisms^g Low (≤ 4 mechanisms) Medium (5 mechanisms) High (6 mechanisms)	15 18 33	22.7 27.3 50.0
Team size Small (≤ 21 members) Medium (21–32 members)Large (>32 members)	24 20 22	36.4 30.3 33.3

Table 2. CPAT scores and team features for participating practices

Team-level variables	Mean	SD
Total CPAT score	46.6	2.5
FHTs only	45.5	3.0
CHCs only	47.2	2.0
Roster/panel size	7873	7420
Years of employment	7.1	3.4
Age	43.3	4.9
Number of professions	12.5	2.1

The average age and length of employment for respondents was 43 years (sd = 4.9) and 7 years, respectively (sd = 3.41). Most practices were based in an urban setting, with rural primary care teams representing only 17% of the sample. Over half of participating practices had 2 or more locations, and average panel size was 7873 patients. There was considerable variability in team size; the smallest team had 10 members and the largest team had 99 staff members. Practices had approximately 30 team members representing on average 12 professions (sd = 2.11). As such provider responses to the CPAT reflected a wide range of professions including family physicians, nurse practitioners, registered nurses, social workers, and dieticians/nutritionists, occupational therapists, chiropodists, physiotherapists, chiropractors, pharmacists, health promoters, and personal support workers.

CPAT scores

The overall response rate to the CPAT across practices was 48.1%. CHCs had a higher response rate (52.1%) compared to FHTs (40.2%). A majority of respondents were female (n = 874), with men representing only 11.5% of the sample (n = 114). The average CPAT score across practices was 46.6 (sd = 2.5) with the distribution of scores revealing a narrow range overall (IQR = 3.5). An independent samples t-test showed that the mean CPAT score was higher for CHCs (47.2; sd = 2.0) than FHTs (45.5; sd = 3.0), (m_diff = 1.71, p = .02). Independent samples t-tests and ANOVA showed no statistically significant differences in provider-level CPAT scores across professions, age, sex, or training levels (i.e., Medical or Bachelor’s degree).

Regression analyses revealed that the use of diverse mechanisms to communicate between providers and staff within teams, increasing the number of years since practice establishment, and increasing quality improvement capabilities, had a positive association with CPAT scores. In contrast, increasing team size, and having a high ranking on the use of centralized processes for administrative functions (i.e., referrals, patient enrollment) along with a high level of information exchange had a negative association with CPAT score. Provider age, profession, sex, and length of employment did not influence CPAT score. The R² was 54.53% and the adjusted R² was 44.23% (p < .01). A summary of regression findings is available in Table 3.

Table 3. Results of multiple linear regression analysis of CPAT scores from participating practices

Characteristic	b	95% CI	P value
Team size
Small	ref
Medium (21–32 members)	−1.56	−2.78 to −0.35	.013
Large (>32 members)	−2.97	−4.29 to −1.68	<.001
Governance board format
Physician-based boards	ref
Community-based boards	0.20	−2.48 to 2.88	.881
Mixed boards	−2.40	−4.56 to −0.25	.029
Information exchange
Low	ref
High	−2.46	−3.76 to −1.16	<.001
Centralized processes
Low	ref
High	−2.10	−3.14 to −1.06	<.001
Quality improvement capabilities*	0.84	0.14 to 1.55	.021
Communication mechanisms
Low	ref
Medium	1.70	0.30 to 3.10	.019
High	2.51	1.00 to 4.00	<.001
Practice type
FHT	ref
CHC	4.00	0.13 to 7.88	.043
Number of years in operation	0.56	0.09 to 1.03	.020
Practice type x Years in operation
CHC x years	−0.51	−0.98 to −0.05	.032

*This variable was treated as continuous.

Discussion

Despite considerable investments and policy reform to promote a shift toward team-based care as the core of primary care reform in many jurisdictions including Ontario, our understanding of the extent of interprofessional teamwork and the factors that enable interprofessional teamwork in primary care teams is still in its early stages.

Findings indicated statistically significant differences in CPAT scores between primary care models, with FHTs having significantly lower CPAT scores compared to CHCs. Higher CPAT scores in CHCs could be attributed in part to the historical presence of providers from a wide range of professions due to their community-focused mandate (Sweetman & Buckley, 2014) that seeks to address the social determinants of health, by delivering medical services in conjunction with health promotion and community programs (Office of the Auditor General of Ontario, 2017). As such shared care that encompasses integration and coordination between providers from a diverse range of professions has been a component of CHC operations since the model was introduced several decades ago (Association of Ontario’s Community Health Centers, 2016; Sweetman & Buckley, 2014). In contrast, FHTs are a relatively newer model of interprofessional care launched in 2006 by the Ministry of Health and Long-term Care. FHTs are not a physician payment model, rather under the FHT program, existing groups of physicians being reimbursed through blended capitation payment models (i.e., the Family Health Network [FHN] and the Family Health Organization [FHO]) could access financial resources to add providers from different professions, and broaden the scope of practice and range of services offered (Sweetman & Buckley, 2014). The FHT model is an evolution of traditional physician-led models, which have undergone a shift to a team-based approach to care delivery via the inclusion of providers from health and social care professions, and this transition from a physician-led model to a team-based lens may not have been fully supplemented by comprehensive and ongoing training on interprofessional teamwork and dedicated education for team members prior to and even after joining the FHT (Gocan et al., 2014).

The number of years a practice has been in operation for had a positive association with CPAT score. The role of temporality in shaping interpersonal interactions between team members is increasingly recognized as a key driver in cultivating interprofessional teamwork (Gregory & Austin, 2016). Past research has also found that the passage of time has an important influence on how relationships between team members grow, mature, and evolve (Bedwell et al., 2012; Kozlowski, 2018; Marks et al., 2001). Participating CHCs had been in operation on average for about 22.5 years (sd = 1.8), whereas participating FHTs had been operational for an average of 8.4 years (sd = 0.5). Time spent with individuals from different professions and training backgrounds promotes an understanding and appreciation of the knowledge, skills, and contributions of different providers to the team, this in turn fosters a sense of mutual respect, which facilitates the development of trust between team members, promotes greater role clarity (Legault et al., 2012; Pottie et al., 2008), and ultimately interdependency between different professionals which cultivates and sustains teamwork (Bushnell & Dean, 1993; Evans, 1994; Gage, 1998; Way et al., 2000). This influence of temporality may also explain why the interaction term between CHC and years in operation indicated that the rate of increase in CPAT scores for every year in operation was lower than that observed in FHTs, since the CHCs have were established in the 1970s compared to the more recent introduction of FHTs. Adequate time to reflect and devise strategies to improve team functioning and staff continuity has been identified as an important facilitator of interprofessional teamwork (Hellman et al., 2016; O’Daniel & Rosenstein, 2008). Frequent and voluntarily interactions between staff from different professions increases the likelihood of sharing ideas (Fay et al., 2010), and developing interpersonal relationships, which are integral to facilitating interprofessional teamwork (Lindeke & Block, 1998; Warren et al., 1998). This finding is in contrast with the work of Howard et al. (2011), which observed a negative association between length of time and provider-level team climate scores in FHTs (Howard et al., 2011). The authors felt this may be related to providers having higher (unmet) expectations around team functioning, particularly from those providers that may have been working together prior to their formal transition to the FHT model (Howard et al., 2011). This could be attributed in part due to the adoption of a more comprehensive focus on interprofessional teamwork for our study, which encompasses some elements of team climate, but also incorporates other aspects of interprofessional team functioning including patient and family involvement, coordination of care and communication, as well as shared power and leadership (Bookey-Bassett et al., 2016).

While past research has observed mixed findings regarding the influence of individual provider characteristics on interprofessional teamwork, including age, sex, years of experience, and level of education (Bloom, 1980; Cohen & Zhou, 1991; Lichtenstein et al., 2004; Matziou et al., 2014), those variables were not found to be statistically significantly associated with provider-level CPAT scores. The average age of respondents or average length of employment was not associated with practice-level CPAT scores. There were no statistically significant differences in CPAT scores across the different professions involved. This is an interesting finding given past research around the presence of power differentials between various professions and training backgrounds (often maintained by social, cultural, and professional systems) (San Martín-Rodríguez et al., 2005), that can reinforce hierarchical structures where power is concentrated among a small subset of providers, thereby inhibiting the operationalization of a truly interprofessional approach toward the organization and delivery of care (Bélanger & Rodríguez, 2008; Lichtenstein et al., 2004).

The role of governance as it relates to interprofessional teamwork in the context of primary care settings is not well understood. Mixed results have been observed; Howard et al found no relationship between governance model (physician, mixed, or community-based boards) and team climate in FHTs (Howard et al., 2011), whereas Beaulieu et al. observed that community-governed practices had lower TCI scores (Beaulieu et al., 2014). CHCs have volunteer community-based governance boards that are comprised of community leaders, patients, and other community members, who collectively offer strategic guidance for CHC programming to ensure that the CHC’s service offerings are reflective of the community’s needs (Office of the Auditor General of Ontario, 2017). Some but not all CHCs offer training to board members who may not have experience in such a role. FHTs may be governed by community or provider-based boards, or a mix of both (Ministry of Health and Long-term Care, 2009). The negative association between the presence of a mixed-governance board and CPAT score is particularly relevant for FHTs, that are a product of a complex transition from traditional physician-only models to a team-based orientation (Hutchison et al., 2011). The adoption of team-based care shifts team dynamics, away from one single group (typically physicians) holding decision-making power and ownership (Ambrose-Miller & Ashcroft, 2016; Baker et al., 2011; Whitehead, 2007), toward a general flattening of power hierarchies, such that other professionals and community members are also engaged in decision-making processes and planning efforts (Ambrose-Miller & Ashcroft, 2016). This may be challenging for physicians who previously may not have encountered resistance from other types of providers and community members, in terms of making managerial decisions and determining the practice’s strategic direction (Hutchison et al., 2011).

Interestingly, ranking highly on the use of centralized approaches to conduct administrative tasks including referrals and scheduling appointments, as well as high levels of information exchange, i.e., the types of information shared between providers and staff were associated with a lower CPAT score. This finding differed from existing literature which has increasingly emphasized the adoption of centralized approaches to more efficiently complete tasks such as intake and referrals (Kodner, D & Spreeuwenberg, 2002) and the use of common processes/protocols for administrative procedures (Sicotte et al., 2002) to facilitate collaboration within teams (San Martín-Rodríguez et al., 2005; Sicotte et al., 2002). The exchange of information between team members is an integral to interprofessional teamwork, since it allows providers from different scopes of practice to have access to the same information so that they are adequately informed to perform their roles (Kvarnström, 2008; S. S. Morgan et al., 2015; Sicotte et al., 2002). These two inverse relationships observed may be a function of a potential disconnect between Executive Director’s and providers, since questions around the use of centralized processes and information exchange were answered by the Executive Director at each practice via the TPS, whereas the CPAT was administered at the individual provider level.

Results showed that the use of a wide range of formal and informal mechanisms to share information across providers had a positive association with CPAT score. This finding is aligned with existing literature on team functioning which has consistently identified effective communication to be the cornerstone of interprofessional teamwork in primary care teams (Bokhour, 2006; Grumbach & Bodenheimer, 2004; Molyneux, 2001), and a core determinant of the efficient flow of information between providers (J. B. Brown et al., 2009). The use of a broad range of communication mechanisms, particularly informal means such as interpersonal interactions in shared common spaces (Croker et al., 2012; Mior et al., 2010; Oandasan et al., 2009), is considered to be instrumental in supporting the creation of new knowledge, promoting shared learning, and the subsequent application of knowledge to clinical decision-making (Bunniss & Kelly, 2008; S. S. Morgan et al., 2015; Quinlan, 2009). Access to shared spaces, hallway consultations and sharing information via informal methods (i.e., sticky notes on computer screens), as well as regular structured meetings involving providers from different professions, represent both formal and informal mechanisms of communication that allow providers to better understand and align on roles and responsibilities for different team members (Ellingson, 2003; S. S. Morgan et al., 2015; Oandasan et al., 2009; San Martín-Rodríguez et al., 2005; Xyrichis & Lowton, 2008).

Increasing a practice’s capabilities around engaging in a range of quality improvement initiatives pertaining to both interprofessional teamwork and overall performance was associated with a higher CPAT score. A commitment to a broader culture of quality improvement within an organization or team has been identified as instrumental in facilitating integration efforts in healthcare organizations (Ouwens et al., 2005). The transition away from traditional physician-led models of care delivery toward interprofessional team-based care requires systematic change management, which is driven by in part by a commitment to quality improvement (Homer & Baron, 2010; Scholle et al., 2013). Quality improvement initiatives, including audits, rapid cycle testing, and the provision of feedback on team performance, can help illuminate current gaps, and identify training needs to improve collaboration efforts (Barceló et al., 2010; Janson et al., 2009), and are increasingly recognized as key enablers of interprofessional teamwork (Sicotte et al., 2002; Wilcock et al., 2002).

Findings also highlight the influence of team size on interprofessional teamwork. As teams grow, there are increased challenges with coordinating and communicating between providers, which can inhibit the cultivation of strong interpersonal relationships (Stott, 1995; Sundstrom et al., 1990). Having the appropriate mix of skills and experience is vital to ensure that the primary care team can effectively offer the right variety of services for their patients; however, this may occur at the expense of interprofessional team functioning. Other studies have also noted an inverse relationship between team size and participation, perceived team functioning (Alexander et al., 1996; Poulton & West, 1999; Shortell et al., 2004) and team effectiveness (Borrill et al., 2000). But restricting team size may be challenging. Practices in this study had on average 30 members on staff. This could be attributed to the wide range of services offered by primary care teams, which requires the addition of interdisciplinary providers to better distribute patient load across staff members (Altschuler et al., 2012). The relationship between team size and interprofessional teamwork requires further exploration given the difficulties that adding team members poses to efficient communication and coordination, and pressures faced by teams to offer a wide range of services especially in light of the growing prevalence of multimorbidity in primary care settings (Fortin, Lapointe et al., 2005).

Another key finding was that the lowest score across domains in the CPAT was observed in the decision-making and conflict management domain. This may reflect challenges faced by professionals as they navigate across scopes of practice to jointly deliver care (J. J. Brown et al., 2011), and represents an important development opportunity for practices to consider ongoing education for conflict resolution training to support interprofessional teamwork (B. B. Brown et al., 2000; J. B. Brown et al., 2015).

Strengths of this study

There was representation from both CHCs and FHTs across the province – about 60% of CHCs in Ontario took part in this research. The overall response rate across the 66 practices that participated in this study was 48.1%, which is consistent with the upper bound of what has been observed in recent primary care-related health services research studies based in Ontario, where response rates ranged between 20% and 49% (Johnston et al., 2010). Overall, about one-quarter of all CHCs and FHTs were represented (with a high response rate across practices), which represents one the largest data collection efforts involving both of Ontario’s interprofessional team-based primary care models. The use of the CPAT instrument to measure interprofessional teamwork offers a comprehensive assessment of the core attributes of interprofessional teamwork as identified in existing literature (Bookey-Bassett et al., 2016). Given its alignment with the foundational attributes of interprofessional teamwork, and high levels of reliability and validity pertaining to its use in primary care settings, the CPAT is considered to be the most appropriate instrument to assess interprofessional teamwork in teams of community-based healthcare and other professionals caring for chronic disease populations (Bookey-Bassett et al., 2016).

Limitations of the study

Due to the cross-sectional design of this study, it is not possible to draw causal inferences based on the associations that were observed. And since the CPAT was voluntary there may be some influence of selection bias pertaining to which providers and practices decided to take part in the study. It is possible that those CHCs and FHTs that are inherently interested in understanding and improving interprofessional teamwork may have been more inclined to participate. Another limitation was low representation from FHTs, which could be attributed in part to the over studying of FHTs by researchers and policymakers over the past decade, and the reliance on the D2D reporting platform for recruitment. About 55% of FHTs in the province participate in the D2D (Association of Family Health Teams of Ontario, 2015a) (which was the main recruitment channel for FHTs) of which an estimated 20% participated in this study. It is worth noting that the average response rate across FHTs was 40.2%, indicating there was strong engagement from those FHTs that did participate.

Conclusion

This systematic assessment of interprofessional teamwork found that CHCs have a higher degree of interprofessional teamwork compared to FHTs. Time since practice establishment, a strong commitment to quality improvement, and the use of diverse formal and informal mechanisms to communicate information between providers were positively associated with interprofessional teamwork. A better understanding of the barriers to interprofessional teamwork, a targeted effort to build competencies pertaining to interprofessional teamwork into education/training curriculum, and a comprehensive assessment of whether interprofessional teamwork influences patient and provider outcomes would be important next steps to consider.

Declaration of Interest/Disclosure statement

The authors report no conflicts of interest. The authors alone are responsible for the content and writing of this article.

Additional information

Funding

This work was supported by research grants to the Health System Performance Research Network from the Ontario Ministry of Health and Long Term Care (Grant # 06034) and the Ontario SPOR Support Unit, as well as funding from the Canadian Institutes for Health Research (Funding Reference Number TTF-128263). No endorsement by the funding sources is intended or should be inferred. The funding sources for this study had no role in study design, data collection, analysis, or interpretation of data, nor in the writing of the manuscript.

Notes on contributors

Anum Irfan Khan

Anum Irfan Khan has a PhD in Health Services Research from the Institute of Health Policy, Management and Evaluation at the University of Toronto. Her research interests include understanding the drivers of interprofessional teamwork in healthcare settings, and exploring the influence of interprofessional teamwork on patient and provider experience and broader health system performance.

Jan Barnsley

Jan Barnsley is an Associate Professor (Emeritus) with the Institute of Health Policy, Management and Evaluation at the University of Toronto. Her research interests are in the areas of performance measurement, program evaluation and health services delivery.

Jenine K. Harris

Jenine Harris is an Associate Professor in public health at the Brown School at Washington University in St. Louis. Her research interests are reproducible research and improving diversity in the STEM workforce.

Walter P. Wodchis

Walter P Wodchis, PhD, is Professor at the Institute of Health Policy, Management and Evaluation at the University of Toronto and Research Chair in Implementation and Evaluation Science at the Institute for Better Health, Trillium Health Partners. His main research interests are health economics and financing and health care policy evaluation. Through his research programs which include more than 30 collaborating researchers and as many trainees, Dr. Wodchis has led several studies examining complex needs of high cost patient groups, the implementation of integrated care programs to address those needs, and evaluations for a number of integrated care programs in Ontario.