Table 3 Article characteristics

Arevian, M., 2005 [87],

USA,

Quantitative

To evaluate the impact of collaborative practice on the quality and cost of effective care for diabetic patients in a primary health care center

Audit process, analysis of patient medical records

Primary health care centre

Team includes general practitioners, social workers, nurses, public health officer, dietician, specialists

The results indicated a high level of enthusiasm, support and the development of team spirit at the process level. At the outcome level there was improvement in documentation, increase in patient recruitment, increase in continuity of care, improvement of glycemic control and decreased cost

Collaborative practice interventions improved process and outcome variables for diabetic patients

It is suggested that this model could be developed for use in the care of other chronic diseases

Healthcare teams can benefit from improvements in documentation in order to increase patient recruitment

Further work is required to explore the impact on quality of patients’ life and satisfaction with the program

Bareil et al., 2015 [88],

Canada,

Qualitative

To better understand the driving forces during the early stage of the implementation process of a community-driven and patient-focused program in primary care titled “TRANSforming Interprofessional cardiovascular disease prevention in primary care” (TRANSIT)

Focus groups, interviews

Members of the primary care community

Various decision makers, family physicians, nurses, nutritionists, pharmacists, and others

The analyses revealed three key forces that facilitated the implementation of interprofessional collaborative practices in primary care:

1. Opportunity for dialogue through the Interprofessional Facilitation Team (IFT)

2. Active role of the External Facilitator (EF)

3. Change implementation budgets

This community-based and patient centered study aimed to implement an interprofessional intervention program in primary care. Interim findings of this qualitative evaluation highlight a trilogy of driving forces: an interprofessional team and IFT, an EF, and change implementation budgets. The three forces should be activated simultaneously because they strengthen one another. Interventions based on interprofessional collaboration in a context in which primary care is undergoing transformation often have proven to be challenging

To address this challenge, change managers should activate an opportunity for dialogue; include the active role of the external facilitator, and change implementation budgets to enhance the implementation process

Beaulieu et al., 2013, Canada,

Mixed Methods [89]

To identify the organizational characteristics of primary care practices that provide high-quality primary care

Cross-sectional observational study. The study used the Organizational Questionnaire, and the Team Climate Inventory to measure Team process

Primary care practices

Primary care practices, patients

Findings suggest high-quality care can be achieved by practices with different organizational models. The authors identified organizational factors that, beyond models, can improve care. As hypothesized, organizational contribution to technical quality differed according to the nature of care considered

The study identified a common set of organizational characteristics associated with high-quality primary care (e.g., effectiveness of team process, presence of competence-maintenance mechanisms, organizational access). Most of these characteristics are amenable to change, through either health policy or practice-level organizational changes

Beyond investing in new delivery models, decision-makers should invest in helping primary care practices reach a high level of functioning by fostering group practice and effective team-based care

Burgess et al., 2011 [90],

Canada,

Qualitative

To explore the meaning of nurse practitioner (NP) role integration to develop a framework

Participatory action research whereby journal articles were shared and discussion of NPs’ patterns of everyday practice, experiences of role development, and factors contributing to collaboration and role integration were explored

Community Health Centre

NPs, physician

The study uncovered 5 dimensions of NP role integration: autonomy, recognition, inclusion, contribution, and alliance

The framework is beneficial for policy leaders, decision-makers, and researchers as it helps them overcome obstacles related to integrating roles, assess the effectiveness of roles, and ensure the safety and protection of the NP role

The framework can be refined and used for policy leaders, decision-makers, and researchers to determine the status of NP role integration within a health-care setting or area and to identify deficiencies and strategies for role advancements

Campbell et al., 2008 [91], UK,

Qualitative

To conduct an in-depth exploration of family physicians' and nurses' beliefs and concerns about changes to the family health care service as a result of the new pay-for-performance scheme in the United Kingdom (Quality and Outcomes Framework [QOF])

Semi-structured Interviews

General Practice

Family doctors, nurses

Participants believed the financial incentives were sufficient to change behavior and to achieve targets. The findings suggest that it is not necessary to align targets to professional priorities and values to obtain behavior change, although doing so enhances enthusiasm and understanding. Participants agreed that the aims of the pay-for-performance scheme had been met in terms of improvements in disease-specific processes of patient care and physician income, as well as improved data capture. It also led to unintended effects, such as the emergence of a dual QOF-patient agenda within consultations, potential deskilling of doctors as a result of the enhanced role for nurses in managing long-term conditions, a decline in personal/relational continuity of care between doctors and patients, resentment by team members not benefiting financially from payments, and concerns about an ongoing culture of performance monitoring in the United Kingdom

The QOF scheme may have achieved its declared objectives of improving disease-specific processes of patient care through the achievement of clinical and organizational targets and increased physician income, but the findings suggest that it has changed the dynamic between doctors and nurses and the nature of the practitioner-patient consultation

Further research is needed to observe the evolution and multiple effects of this dynamic pay-for-performance scheme

Campbell et al., 2010 [92], UK,

Quantitative

To examine patient reports of quality of care between 2003 and 2007

Questionnaires

General practice

General practices, patients

There were no significant changes in quality of care reported by the study sample between 2003 and 2007 for communication, nursing care, coordination, and overall satisfaction. The findings also suggest that patients in the United Kingdom are significantly less likely to report being able to make an appointment with their usual physician, and they report lower ratings of continuity of care in 2007 compared with 2003. This finding was observed in patients with chronic illness and in population samples of patients. It may not be surprising that continuity has decreased when initiatives to improve access to physicians have been prioritized

There is relative improvement in access to care for patients with chronic illnesses, but all patients from the study noted finding it harder to obtain continuity of care. This outcome can be related to the incentives to provide rapid appointments for patients or to the increased number of specialized clinics in primary care

The possibility of unintended effects needs to be considered when introducing pay for performance schemes

Campbell et al., 2011 [93], UK,

Qualitative

To explore GP and practice staff views and experiences of exception reporting in the Quality and Outcomes Framework (QOF)

Semi-structured Interviews

General Practice

General practitioners, 20 practice managers, 13 practice nurses, and nine other staff

Three key themes emerged in the data related to exception reporting: •reasons for exception reporting;

•the level and appropriateness of exception reporting; and • the threat of external scrutiny on behaviour. This study suggests that practise staff view exception reporting as a crucial and clinically essential component of the QOF. Exempting patients was typically regarded as a "exception to the rule," and improper exempting was frequently carried out by "other" practises.When exception reporting was used, it was either justified in terms of providing patient-centered care within a framework of population-based health measures or because the indicators' poor face validity for specific patients

Exception reporting is seen by most GPs and practice staff as an important and defensible safeguard against inappropriate treatment or over-treatment of patients. However, a minority of practitioners also saw it as a gaming mechanism

The majority of practises would benefit from employing exception reporting as a clinical safeguard to high-quality, individualised patient care within a flexible, evidence-based framework

Cashman et al., 2004 [94],

UK,

Qualitative

To foster and guide the development of interdisciplinary healthcare teams towards a collaborative, integrated approach to care delivery, and to evaluate the effectiveness of this approach by assessing values known to reflect effective team functioning

Questionnaire survey called "The System for the Multiple Level Observation of Groups (SYMLOG)" was used

Community Health Centre

Family practice physicians, nurse practitioners, and physician assistants

Properties include (a) the heterogeneity of team composition, (b) role conflict and role overload, (c) constraints placed on members by the larger organizational structure, and (d) members' lack of knowledge about the process of team development. These properties are considered generic and widely applicable

Team members' objective assessments, as well as their lived experiences, provide detailed reaffirmation that, in order to sustain effective team functioning, organisational structures and reward systems must be aligned so that they can support the team's vision and goals, is particularly significant in this study

Intentional team training and development, combined with dedicated time for team meetings, can result in team members expressing values consistent with high functioning teams

Methods for reducing team turnover are also required to ensure that interdisciplinary teams grow

Cassou et al., 2020 [95],

France,

Quantitative

To explore the overall effect of practicing in multiprofessionalprimary care groups (MPCG) on GPs’ income in the context of the French reform in which GPs are considered the pillar of any MPCG. To this aim, the authors analyze the impact of MPCGs on GPs’ medical activity in terms of both the quantity of medical services and the number of patients seen, to highlight the organizational features of MPCGs and their impact with respect to FFS and capitation payments

Administrative database that combined National Health Insurance data

Multi-Professional Primary Care Groups (MPCGs)

General practitioners (GPs), nurses, pharmacist, dental surgeons, specialist, other care providers (unspecified)

The study found that General Practitioners (GPs) enrolled in MPCGs experienced an increase in income 2.5% higher than that of other GPs during the period studied. Moreover, these GPs saw a greater increase in the number of patients (88 more) without involving a greater increase in the quantity of medical services provided. A complementary cross-sectional analysis for 2014 revealed that these changes were not detrimental to quality in terms of bonuses related to the French pay-for-performance program for that year

The results suggest that labor and income concerns should not be a barrier to the development of MPCGs, and that MPCGs may improve patient access to primary care services.

A greater increase in the number of patients seen by the GPs’, were not detrimental to quality in terms of bonuses related to the French pay-for-performance program for the year 2014

Support the organizational properties of teamwork to help GPs in MPCGs to see and follow more patients without increasing the quantity of their delivered services.

Policymakers should support MPCGs as it increases GPs’ ability to treat a larger number of patients without increasing the quantity of services

Delva et al., 2008 [96], Canada,

Qualitative

To explore the views of members of primary health care teams regarding what constitutes a team, team effectiveness and the factors that affect team effectiveness in primary care

Focus groups; Surveys (Team Survey by Delva and Jamieson, 2006)

Academic Clinical Setting

Members of the Department of Family Medicine at Queen’s university. Residents, secretaries, float/replacement nurses, nutritionists, social workers, and administrative staff varied among these teams. Two teams were uni-professional: an administrative/management team (four members) and a nursing team (nine members)

Twelve themes were identified that related to the impact of dual goals/obligations of education and clinical/patient practice on team relationships and learners; the challenges of determining team membership including non-attendance of allied health professionals except nurses; and facilitators and barriers to effective team function

Cultural shifts in primary care that embrace all team members (i.e., professional and support staff) and learners will be important if interprofessional teamwork is to be modeled and learned in academic practice settings

Further research based on modern concepts of complex adaptive systems is needed to determine how best to support the changes needed to implement effective teamwork in primary care

Dieleman et al., 2004 [97], Canada,

Qualitative

To examine the perceptions of pharmacists, physicians and nurses as they worked together in community-based teams to provide care to 199 high-risk community dwelling individuals

Pre- and Post- test design; Questionnaires

Community-based health center

Nurses, Pharmacists, Practitioners

The results indicate that the providers found that working in a team environment was very useful when they dealt with complex primary-care patients. The study results also show that providers relied on their team members for support, after learning the various skills and knowledge offered by each team member. Communication is also a significant aspect of team effectiveness, as it played a role in the overall satisfaction of the team. The results are aligned with previous studies that found collaborative workspaces positively impact job satisfaction

This study concludes by stating that empirical information about community teams requires research, specifically examining the importance of open communication, respect, and understanding the expertise of other members

NR

Dimitrovova et al., 2020 [98],

Portugal,

Quantitative

To evaluate the impact of the Family Health Units (FHUs) implementation on population health outcomes, measured by the rate of hospitalizations for ambulatory care sensitive conditions (ACSC), i.e. avoidable 

hospital inpatient admissions, and to explore the effectiveness of the pay-for-performance in primary care by analysing the subset of disease specific hospitalizations for ACSC related to the financial incentives

Portuguese Central Administration of the Health System and the National Institute for Statistics

Family Health Units (FHU)

General practitioners, nurses, administrative technicians

The results showed that there were no statistically significant changes in disease-specific hospitalization rates as a result of the implementation of the FHUs targeted by the pay for perforamce (P4P). There was no significant impact of FHU implementation on the reduction of ACSC hospitalization rates, including the ACSC-incentivized hospitalizations. The only statistically significant effect of FHU implementation was a reduction in the rate of urinary tract infection ACSC, which was a non-incentivized area

No significant impact of the FHUs implementation on the reduction of the hospitalization rate for ACSC was found. This result also held for conditions specifically incentivized by the P4P scheme. This finding, questions the capacity of P4P payment mechanism to achieve better health outcomes, and invites a more careful and evidence-based action toward its wider diffusion

Decision-makers should be cautious when assuming payment mechanisms will achieve better health outcomes

Doran et al., 2006, UK [99],

Quantitative

To examine the performance of family practices in England in the first year of the pay-for-performance program between April 2004 – March 2005

Data analysis of practice performance on the clinical indicators operated by the Natioal Health Service(NHS) information centre; United Kingdom census

Family Practices

Patients, Family Practice physicians

Results indicate in the first year of the pay-for-performance program, English family practitioners performed extremely well with respect to the quality targets, which explains that financial incentives affect physician behavior

The United Kingdom experience suggests that greater changes in professional practice can be achieved through pay-for-performance programs

Financial incentives should be aligned to physicians' professional values to avoid serious distortions of care

Doran et al., 2008 [100], UK,

Quantitative

To examine the relation between socioeconomic inequalities and delivered quality of clinical care in the first 3 years of the quality and outcomes framework financial incentive scheme

Data analysis of practice performance on the clinical indicators operated by the NHS information centre; United Kingdom census

General Practices

General practitioners, Patients

Results suggest that financial incentive schemes have the potential to make a substantial contribution to the reduction of inequalities, improvement of care delivery of clinical care related to area deprivation

Generation of more equitable provision of prevention and care for these disorders means that the use of financial incentives seems to have the potential to make a substantial contribution to the reduction of health inequalities

NR

Doran et al., 2010, UK [101],

Quantitative

To describe the comparative performance of small practices on the United Kingdom's pay-for-performance scheme, the Quality and Outcomes Framework (QOF)

Longitudinal analysis

Family Practice

Family physicians, patients

Aspects of quality are associated with smaller practices, such as patient ratings of access or continuity of care, while others are associated with larger practices, such as data recording or organization of services. However, it's important to note that there is no consistent association between practice size and differences in outcomes

The effect of the pay-for-performance scheme appears to have been to reduce variation in performance, and to reduce the difference between large and small practices

NR

Drew et al., 2010 [102], Canada,

Mixed Methods

To explore the level of perceived team effectiveness in primary care networks (PCNs) within three health regions in Alberta, Canada as determined by the Team Effectiveness Tool (TET). A secondary exploratory objective was to identify strategies, including team composition, that relate to team effectiveness in the PCNs

Semi-structured questionnaire study design, using the Team Effectiveness Tool (TET)

Primary Care Networks

Physicians, registered nurses, licensed practical nurses, physical therapists, administrative-related positions, and team members with mixed designations

The results identified strategies related to regular meetings/communication, team development and, to a lesser degree, purpose/goals identified as helpful in developing team effectiveness. Leadership was not highlighted; instead, frequent regular meetings was consistently identified, as were innovation in service delivery and role clarification

Findings suggest a need for strategies to focus on regular and frequent meetings as a communication tool in the primary care team setting. Additionally, the areas of relative weakness – team partnership, team purpose and vision and team roles – might benefit from growth. A redistribution of resources (time, money, energy) to these areas might help teams become better rounded. In particular, team partnership is clearly an area of weakness among the teams studied, and it might be strategic for PCNs to prioritize addressing and bolstering this component

Explore the application of the TET instrument in the process of developing some standardized evaluation for PCNs

Drummond et al., 2012 [103],

Canada,

Mixed Methods

To explore the status and processes of interprofessional work environments and the implications for interprofessional education in a sample of family medicine teaching clinics

Semi structured focus group interviews using a purposive sampling procedure

Academic family medicine clinics

7 family physicians, 1 registered nurses, 5 licensed practical nurses, 2 residents, 1 psychologist,

1 informatics specialist, 1 pharmacist, 1 dietitian, 1 nurse practitioner, 1 receptionist, and 1 respiratory therapist

The study suggests that having leaders who prioritize interprofessional collaborative clinical work is crucial for the growth and continuity of interprofessional practices and the related interprofessional education

The study concluded that the existence of clear and explicit leadership towards interprofessional work and education was the key factor in the implementation of interprofessional work in primary care. The study suggested that there is substantial scope for improvement in the organization, conduct, and promotion of interprofessional education for Canadian primary care

Primary care teams should implement clear and explicit leadership

Gemmell et al., 2009 [104], UK,

Quantitative

To describe changes in practice team size and composition, and the workload of doctors and nursing staff, before (2003) and after (2005) the introduction of the pay-for-performance contract for general practice

Practice profile questionnaires and staff workload diaries

General Practice

Doctors, nursing staff

The findings suggest that expanding nursing staff roles may be an effective strategy for increasing the quality of primary care. The number of practice staff increased with greater increases observed for nursing staff than doctors. There was no change in the average number of hours worked per week by nursing staff or doctors but nurse visit rates increased while doctors' rates decreased

General practices may have responded to the 2004 contract by increasing staffing levels, with nursing staff absorbing a higher proportion of the clinical workload and doctors focusing more attention on chronic and preventive care

Expanding nursing staff roles may increase the quality of primary care but may lead also to intensification of nurses' work

Gene-Badia et al., 2007 [105], Spain,

Quantitative

To assess whether the implementation of these economic incentive schemes has had an impact on the quality of professional life (QPL) of both physicians and nurses and on end-user satisfaction

Before-after study

Primary Care Teams

Physicians, nurses

The results show that there is a relationship between the implementation of economical incentives and changes in the Quality and Productivity Level (QPL) of health personnel, as well as end-user satisfaction. The introduction of economical incentives can incentivize health personnel to improve their performance and meet quality targets, leading to positive changes in the QPL. This, in turn, can impact end-user satisfaction, as improved quality of care is likely to result in higher satisfaction among patients or service users. The specific nature and magnitude of these relationships may vary depending on the specific context and implementation of the incentives

Incentives related to quality of care annual targets may increase physicians' perception of burden and it may have a negative impact on consumer satisfaction. Incentives on long-term professional development seem to be related to an increase in professionals' perception of support from the management structure. Among nurses, this increase is related to an improvement of user satisfaction

Analyze professional incentives impact on relevant outcome measures before spreading such reforms to a broad amount of professionals

Glazier et al., 2016 [106],

Canada,

Quantitative

To compare outcomes of family Health Teams (FHT) patients in relation to other major models of primary care in Ontario, over time

Administrative datasets, FHT demographics

FHT, Community Health Center (CHC)

Physicians, patients

FHT and other capitation-based models have somewhat wealthier and healthier populations than other models of care. Given that physicians had a free choice of models, these patterns likely reflect the way that payment incentives such as capitation and bonuses favour certain types of practices

FHT generally performed well in cancer screening and diabetes care, with improvements over time that were larger than those of fee-for-service models but not consistently better than other capitation models. Improvements over time in cancer screening in FHTs were not consistently better than in CHCs

The findings about FHT trends over time should be placed in the context of the work performed by the Conference Board of Canada in its FHT evaluation

Glazier et al., 2012 [39],

Canada,

Quantitative

To characterize primary

care models in Ontario by demographics,

practice location and case mix and to examine emergency department (ED) use by patients/clients in each model before and after controlling for their characteristics

CHC data, the Registered Persons Database; physician

billings from the Ontario Health Insurance

Plan; hospital Discharge Abstract Database;

ED visits from the National Ambulatory Care

Reporting System; the Ontario Drug Benefit Program; Client Agency Program Enrolment

tables, the Rurality Index of Ontario for urban–rural residence, and 2006 Census of

Canada data for sociodemographic variables

Community Health Centres, Family Health Groups, Family Health Networks, Family Health Organizations

Physician, nurse practitioner, and other non-physician providers

Physician, nurse practitioner, and other non-physician providers

Ontario’s primary care models serve different populations and are associated with different outcomes. A move away from fee-for-service reimbursement may be desirable for a high functioning health care system, but how alternate payment mechanisms are structured appears to matter a great deal. The largest current models of care have been costly but have had limited impact on population access to care, which was a key aim. The capitation and team models that have received the most resources are looking after relatively advantaged groups and are associated with higher than expected ED visits

The existing bonus payment aimed at discouraging the utilization of emergency medicine services appears to be ineffective in achieving its intended purpose and can be revisited.

Modify capitation rates to consider healthcare needs, with the objective of attracting a greater number of high-needs patients and practices to participate in these models

Goldman et al., 2010 [107],

Canada,

Qualitative

To examine the perspectives and experiences of family health team (FHT) members regarding interprofessional collaboration and perceived benefits

Semi structured interviews

Family Health Teams

Family physicians, nurse practitioners and nurses,

pharmacists, managers, social workers, and dietitians

The study identified the essential role of the FHT manager and physician leadership in supporting and sustaining an interprofessional FHT. The physical layout of the FHT's central practice space was another important factor that can promote or inhibit interprofessional collaboration. The study documented the different strategies and initiatives being used by the FHTs to support interprofessional care, which can be categorized into organizational, practice-based, and educational interventions. Participants perceived that FHTs were progressing toward an interprofessional approach to delivering care, which was making positive changes in patient care, but further evaluation is required to understand the relationship to the realities of accessibility of care and improvement in patient health outcomes

The study concluded that effective team-based primary care requires addressing issues such as roles and scopes of practice, leadership, and space, and provided a framework for understanding different types of interprofessional interventions used to support interprofessional collaboration

Supporting roles and scopes of practice, leadership, and space to contribute to effective team-based primary care

Grant et al., 2009 [108], UK,

Mixed Methods

To report the impact of the new 2004 General Medical Services (nGMS) contract which prioritizes the ‘Quality and Outcomes Framework’ (QOF), and the financial incentives contained within it on professional boundaries in United Kingdom general practice

Field notes (ethnography)

General Practice Clinics

General Practitioners, Nurses

The four practices in this study illustrate the complexity of recent changes taking place in UK general practice through the financial incentives embedded in the QOF. The most significant change is the way in which practices have created internal QOF teams that cut across traditional clinical and administrative hierarchies and boundaries. These were not as clearly contested by participants as the changes that were taking place at the more established clinical boundaries, which were readily accounted for through the use of existing rhetorical strategies

The creation of new managerial roles through the QOF has reinforced and significantly extended an existing trend towards ‘bureaucratization’ and professional restratification within general practice, with QOF teams drawn from a range of disciplines

NR

Greene et al., 2014 [109],

USA,

Mixed Methods

To examine primary care providers’ (PCPs) perception of the early impact of the compensation model on practice and satisfaction

In-Depth Interviews and online survey

Primary care clinics

Family medicine physicians, internist, pediatrician, nurse practitioners, and physician assistant

The team-based, quality-focused compensation model was effective in improving the quality of care and patient outcomes. The compensation model encouraged collaboration and teamwork among providers, which led to improved patient care. The model incentivized providers to focus on preventive care and chronic disease management, which resulted in better health outcomes for patients. The compensation model was financially sustainable and cost-effective, as it reduced the need for costly hospitalizations and emergency room visits. The comprehensive change did, however, result in lower fee-for-service billing and reductions in PCP satisfaction

PCP participation in design of compensation model is important. Prepare PCPs for the challenges of compensation at the team level. Minimize complexity and changes in the model. Transparency in PCPs’ quality performance can be powerful

motivator. Do not let the compensation model get ahead of the revenue

stream

Provide opportunities for ongoing feedback from PCPs

Provide training, tools, and support to help prepare PCP for organizational changes, and help them with the skills they will need to collaborate

Hämel et al., 2017 [110],

Germany,

Qualitative

To take a closer look at possibilities of cooperation between GPs and nurses in primary care in Slovenia and Spain in the context of their country-specific primary care concepts and further refinement. The comparative analysis enabled us to identify differences in conceptual and procedural methods employed in the two countries

Background review of primary care concepts (literature analysis, expert interviews)

Primary care team

Physicians and nurses

The introduction of a new cross-professional primary care

concept has integrated advanced practice nurses into general practice. Conventional hierarchies still exist, but a shared vision of preventive care is gradually strengthening attitudes

towards team-oriented care. Formal regulations or incentives for teamwork have yet to be implemented. In Spain, health centres were established along with a team-based care

concept that encompasses close physician–nurse collaboration and an autonomous role for nurses in the care process. Nurses collaborate with general practitioners on more equal terms with conflicts centring on professional disagreements. Team development structures and financial incentives for team achievements have been implemented, encouraging teams to

generate their own strategies to improve teamwork. Furthermore, collaboration results in increased accessibility to a diverse range of expertise and skills among all team members, ultimately benefiting patient care

Team development structures and financial incentives for team achievements have been implemented, encouraging teams to generate their own strategies to improve teamwork

Invest in clearly defined structures, shared visions of care and team development

Harris et al., 2016 [111], Canada, Australia, USA,

Qualitative

To assess the impact of reform policies and interventions that have aimed to create or enhance teamwork on professional communication relationships, roles, and work satisfaction in primary health care (PHC) practices

Synthesis and secondary analysis

Primary Care Practices

Primary care teams

The results show a diverse range of complex reforms seeking to foster interprofessional teamwork in the care of patients with chronic disease. The impact on communication and relationships between different professional groups, the roles of nursing and allied health services, and the expressed satisfaction of PHC providers with their work varied more within than between jurisdictions. These variations were associated with local contextual factors such as the size, power dynamics, leadership, and physical environment of the practice. Unintended consequences included deterioration of the work satisfaction of some team members and conflict between medical and nonmedical professional groups

The variation in impacts can be understood to have arisen from the complexity of interprofessional dynamics at the practice level. The same characteristic could have both positive and negative influence on different aspects (eg, larger practice may have less capacity for adoption but more capacity to support interprofessional practice). Thus, the impacts are not entirely predictable and need to be monitored, so that interventions can be adapted at the local level

Policymakers need to be aware of the complexity of the PHC context into which reforms are introduced and the consequent variation in impacts and responses.

Hepp et al., 2014 [112],

Canada,

Qualitative

To examine organizational factors influencing the functioning of inter-professional teams in select primary care

networks (PCNs) in Alberta

Face-to-face and telephonic interviews

Primary Care Networks

Team includes; dietitian, exercise specialists, manager, registered nurse, mental health clinician, pharmacist, physician, physiotherapist, resource navigator, social worker, office assistant etc

The study highlights that physical infrastructure was a barrier to team functioning, especially inadequate space negatively affecting relationship building, collaboration, and access to expertise. Co-location of team members in a PCN office facilitated collaboration, communication, and relationship building, but impeded day-to-day interactions between interprofessional team members and physicians. Decentralization allowed relationships and trust to build between physicians and team members working together in physicians' clinics but communicating with busy physicians was a challenge at these sites due to time constraints or limited private space

This study focuses on some of the organisational factors that influence team performance, such as leadership and managerial decision-making. Although researching these factors is a step forward in understanding teams from an organisational standpoint, more research on outcomes is required to fully understand organisational strategies and their impact on interprofessional teams and patient care

Create an interdisciplinary management team.

Engage all stakeholders during development to identify service grants.

Foster a culture of respect, continuous learning and improvement.

Allow co-location

Acknowledge the good work staff do.

Develop an integrated EMR system between and across physician clinics and PCN offices.

Orient new employees and provide ongoing education.

Promote physician buy-in and support by compensating physicians for time meeting. Provide education and offering shadowing days where physicians observe interprofessional professional teams in action.

Khan et al., 2022 [113],

Canada,

Quantitative

To examine interprofessional teamwork within primary care practices (Family Health Teams [FHT] and Community Health Centers [CHC]) in Ontario and to investigate team-level and organisational factors related to interprofessional teamwork

The study used the Collaborative Practice Assessment Tool (CPAT) to assess the extent of interprofessional teamwork within participating primary care practices. A team profile survey was used to assess organizational characteristics

CHC and FHTs

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

The study indicated that there were statistically significant differences in CPAT scores (a measure of interprofessional teamwork) between primary care models, with Family Health Teams (FHTs) having lower CPAT scores compared to Community Health Centers (CHCs). 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

There are several factors that may need to be addressed to support and enhance interprofessional teamwork among healthcare providers

The transition from physician-led model to a team-based lens requires comprehensive and ongoing training on interprofessional teamwork and dedicated education for team members prior to and even after joining the FHT

Khazei et al., 2020 [114],

Canada,

Quantitative

To assess self-rated team climate, intrinsic motivation, and burnout of a multidisciplinary team at an urgent primary care center and to explore potential relationships between the concepts

Survey administration

Multidisciplinary teams striving to achieve the Quadruple Aim

Physicians (general practitioners, family medicine physicians, and emergency physicians), nurse practitioners, registered nurses, patient care coordinators, radiology technologists, medical office assistants, laboratory assistants, pharmacists, and mental health and substance-use clinicians

The survey findings indicate a relatively high-performing multidisciplinary team, with high scores in all categories related to team climate and intrinsic motivation. Only 8% of 25 respondents met the threshold level of burnout, with

no respondents indicating severe or complete burnout. Reliability analysis produced α coefficients of 0.956 and 0.945 for team climate and intrinsic motivation, respectively, indicating satisfactory reliability

The study fills a gap in the health services research literature pertaining to the performance of multidisciplinary teams

Future research is needed that focuses on the survey tool developed in this study across various organizational settings and context.

Rather than focusing on extrinsic factors, the focus should be intrinsic motivation as it relates to, team climate, and burnout

Kiran et al., 2012 [115],

Canada,

Quantitative

To assess diabetes incentive code introduced for primary care physicians in Ontario, Canada, in 2002 on quality of diabetes care at the population and patient level

Administrative database: Ontario Diabetes Database (ODD)

Diabetes incentive codes/model

Endocrinologist or general, primary care

physician visits

One-quarter of Ontarians with diabetes had an incentive code billed by their

physician. The proportion receiving the optimal number of all three monitoring tests (HbA1c,

cholesterol, and eye tests) rose gradually from 16% in 2000 to 27% in 2008. Individuals who were younger, lived in rural areas, were not enrolled in a primary care model, or had a mental illness were less likely to receive all three recommended tests. Patients with higher numbers of incentive code billings in 2006–2008 were more likely to receive recommended testing but also were more likely to have received the highest level of recommended testing prior to introduction of the incentive code

The shift to capitation payment and the addition of team-based care in Ontario were associated with moderate improvements in processes related to diabetes care, but the effects on cancer screening were less clear

Financial incentives may be a useful tool for improving diabetes care quality, but social and structural factors that affect health outcomes need to be explored

Kirschner et al., 2013 [116], Netherlands,

Quantitative

To assess changes in performance after introducing a participatory pay-for-performance (P4P) program

Pre- and Post-measurement

General practices

General practitioners, patients

Introduction of a participatory P4P program yielded significant improvements in care delivery. Clinical care indicators, pertaining to both process and outcome

A participatory P4P program might stimulate quality improvement in clinical care and improve patient experiences with general practitioner functioning and the organization of care

More studies are needed in which the appraisal and reimbursement are based on drivers taken from behavioural economics

LaMothe et al., 2021 [117],

USA,

Mixed Methods

To describe the facilitators and barriers of Interprofessional Collaborative Practice (IPCP) implementation in rural clinics and the impact on decision-making and safety culture

Survey administration and Qualitative Interviews

Interprofessional Collaborative Practices

Provider (medical doctor

or nurse practitioner), a registered nurse, psychologist or

social worker, and other clinical staff

Significant improvement in the Global Amount of Collaboration made over time. Barriers to IPCP included high turnover, hierarchical culture, lack of role clarity, competing time demands, limited readiness for change, and physical space limitations. Facilitators included structured huddles, alignment of IPCP with organizational goals, and academic-practice partnership

The study highlighted the need and appreciation for ongoing support and guidance for team development and reinforcement. Leveraging the resources of the academic-practice partnership was key to the success of the project

Future research should examine the impact of facilitated approaches to support interdisciplinary teamwork and collaboration competencies

Lanham et al., 2009 [118], USA,

Qualitative

To understand the characteristics of relationships within primary care practices

Data analyzed from National Institutes of Health (NIH)-funded studies; Observation of practices during work activities and of patient-clinician interactions; In-depth interviews with physicians and other key staff members; surveys; structured checklists

Primary care practice

Physicians, healthcare staff

Trust, mindfulness, heedfulness, respectful interaction, diversity, social/task relatedness, and rich/lean communication were identified as important in practice improvement. A model of practice relationships was developed to describe how these characteristics work together and interact with reflection, sensemaking, and learning to influence practice-level quality outcomes

Although this model of practice relationships was developed from data collected in primary care practices, which differ from other health care organizations (HCOs) in some important ways, the ideas that quality is emergent and that relationships influence quality of care are universally important for all HCOs and all medical specialties

NR

Lehtovuori et al., 2015 [119],

Finland,

Quantitative

To examine whether it is possible to improve clinical practice by increasing the recording of diagnoses using financial incentives to all disciplines in the care team (e.g. group bonuses)

The data was specifically derived from the electrical patient chart

system (Tieto LTD, Helsinki, Finland)

Municipal health service teams

There were 6–8 doctors and 6–8 nurses per team

The proportion of doctor visits having recorded diagnoses in the teams was about 55% before starting to use group bonuses and 90% after this intervention. There was no such increase in control units. The effect of the intervention weakened slightly after cessation of the group bonuses

Group bonuses may provide a method to improve clinical practices in primary care. Yet the putative desired effects obtained with these financial incentives may slowly start to erode if these bonuses are withdrawn

Group bonuses may provide a method to improve clinical practices in primary care

Lester et al., 2013, UK [120],

Qualitative

To obtain a longer-term perspective on the implementation of the Quality and Outcomes Framework (QOF) from General Practitioners and primary healthcare teams before memories of working in a pre-pay-for-performance era became less reliable

Semi-structured interviews

Healthcare practices, and General practice clinics

General Practitioners (GPs)

Pay for performance is accepted as a routine part of primary care in England, with previous more individualistic and less structured ways of working seen as poor practice. The size of the QOF and the evidence-based nature of the indicators are regarded as key to its success. However, pay for performance may have had a negative impact on some aspects of medical professionalism, such as clinical autonomy, and led a significant minority of GPs to prioritise their own pay rather than patients' best interests

Pay for performance indicators are now welcomed by primary healthcare teams and GPs across generations. Almost all interviewees wanted to see a greater emphasis on involving front line practice teams in developing indicators. However, almost all GPs and practice managers described a sense of decreased clinical autonomy and loss of professionalism

Calibrating the appropriate level of clinical autonomy is critical if pay for performance schemes are to have maximal impact on patient care

MacNaughton et al., 2013 [121],

Canada,

Qualitative

To explore how roles are constructed within interprofessional health care teams, including the different types of role boundaries, the influences on role construction, and the implications for professionals and patients

The data collection included interviews and non-participant observation of team meetings

Primary health care teams

Clinical director, manager, nurse practitioners, physician, registered nurses and registered practical nurse), pharmacist, dietician, social worker, mental health counselor, chiropodist, laboratory technician, administrative assistant

The study found that role boundaries can be organized around interprofessional interactions (autonomous or collaborative roles) as well as the distribution of tasks (interchangeable or differentiated roles). Different influences on role construction were identified, including structural, interpersonal, and individual dynamics. The study also found that empowering team members to develop autonomy can enhance collaborative interactions, while more interchangeable roles could increase the potential for power struggles

The study identified three categories of influences on role construction in interprofessional health care teams: structural factors related to the workplace, interpersonal factors such as trust and leadership among team members, and individual dynamics including personal attributes. The implications of role construction included professional satisfaction and improved wait times for patients

Develop strategies for empowering team members to develop autonomy can enhance collaborative interactions

Maisey et al., 2008 [122], UK,

Qualitative

To understand the effects of a large scale 'payment for performance' scheme (the Quality and Outcomes Framework [QOF]) on professional roles and the delivery of primary care in the English National Health Service

Semi structured interviews

General practice

24 Clinicians, 1 general practitioner, 1 practice nurse

Participants reported substantial improvements in teamwork and in the organization, consistency and recording of care for conditions incentivized in the scheme, but not for non-incentivized conditions. The need to carry out and record specific clinical activities was felt to have changed the emphasis from 'patient led' consultations and listening to patients' concerns. Loss of continuity of care and of patient choice were described. Nurses experienced increased workload but enjoyed more autonomy and job satisfaction. Doctors acknowledged improved disease management and teamwork but expressed unease about 'box-ticking' and increased demands of team supervision, despite better terms and conditions. Doctors were less motivated to achieve performance indicators where they disputed the evidence on which they were based. Participants expressed little engagement with results of patient surveys or patient involvement initiatives. Some participants described data manipulation to maximize practice income. Many felt overwhelmed by the flow of policy initiatives

Payment for performance is driving major changes in the roles and organization of English primary health care teams. Non-incentivized activities and patients' concerns may receive less clinical attention

Practitioners would benefit from improved dissemination of the evidence justifying the inclusion of new performance indicators in the QOF

Markon et al., 2017 [123],

Canada,

Quantitative

To estimate the

associations and predictive relationships among these variables and to test, through structural equation modelling,

whether the data fit the theoretical model formulated under the Input-Mediator-Outcome-Input framework and correspond with existing literature on the variables of interest

Questionnaires administered

Local health service

networks (being a member of a public mental health specialised care

or primary care team comprising at least three members from

two or more professions)

Front-line practitioners (e.g. general physicians, social workers, and nurses) and specialists (e.g. psychiatrists)

The structural equation model provided a good fit for the data and explained 51% of the variance of work role performance. Perceived collaboration, and confidence in the advantages of interprofessional collaboration, involvement in the decision processes, knowledge sharing, and satisfaction with the nature of the work partially mediated the effect of perceived interdependence among team members on work role performance. Therefore, perceived interdependence among team members had a positive impact on the work role performance of mental health care professionals mostly through its effect on favourable team functioning features

Increased interdependence of mental healthcare professionals would be more likely to enhance work role performance if team-based interventions promote collaborative work and interprofessional teaching and training programs are jointly implemented. Participation in the decision process and knowledge sharing should also be fostered, by adopting knowledge management best practices

Healthcare managers should promote collaborative work, knowledge sharing, and participation in decision-making

McDonald et al., 2007 [52], UK,

Qualitative

To explore the impact of financial incentives for quality of care on practice organisation, clinical autonomy, and internal motivation of doctors and nurses working in primary care

Ethnography (field notes); interviews

General Practice

12 general practitioners, nine nurses, four healthcare assistants, and four administrative staff

Three major themes emerged after the introduction of the quality and outcomes framework: the alignment of financial incentives with professional values; concerns about changes to clinical practice; and the impact of surveillance within practices. Doctors and nurses generally reported that the quality and outcomes framework helped them provide what they regarded as high quality clinical care. Some concern was expressed that care might suffer from the introduction of targets that required respondents to do things that they did not regard as routine good clinical practice

Implementation of financial incentives for quality of care did not seem to damage the internal motivation of the general practitioners studied, although more concern was expressed by nurses

NR

McGregor et al., 2008 [124], UK,

Qualitative

To investigate how practice nurses perceive the changes in their work since the General Medical Services (GMS) contract, including the Quality and Outcomes Framework (QOF) contract's inception

Individual interviews

Primary care

Nurses

Nurses were positive about the way in which their role has developed since the new contract but there were concerns about incentives, in particular financial reward for the amount of work they had carried out, and about the impact of QOF on the patient–nurse relationship. Roles and incentives were discussed in relation to two issues: professional development and professional status. Most practice nurses felt they had expanded their role and taken on new skills, particularly in chronic disease management and data recording, since the implementation of the new GMS contract. This view was consistent across practices, regardless of the level of QOF achievement or the socioeconomic profile of the practice population

The new GMS contract increased responsibility of practice nurses increased responsibility. However, discontent about how financial gains are distributed and negative impacts on core values may lead to detrimental long-term effects on motivation and morale

NR

Mayo-Bruinsma et al., 2013 [125],

Canada,

Quantitative

To determine whether models of primary care service delivery differ in their provision of family-centered care (FCC) and to identify practice characteristics associated with FCC

Patient and provider surveys based on the Primary Care Assessment Tool

Community health centres (CHCs), in which physicians receive a set annual salary; health service organizations (HSOs), in which payment is capitation based; and family health networks (FHNs), in which remuneration is principally capitation based

General practitioners, nurses and nurse practitioners

This study suggested that organizational characteristics, such as the number of clinical services offered, nurse practitioners, and family physicians, as well as the rural nature of the practice, can influence provider-reported FCC. Patient-reported FCC was not significantly different across primary care models and was mainly influenced by patient-level factors

Based on provider and patient reports, primary care reform strategies that encourage larger practices and more patients per family physician might compromise the provision of FCC, while strategies that encourage multidisciplinary practices and a range of services might increase FCC

To improve family-centered care healthcare leaders should promote multidisciplinary practices and the delivery of a range of services

Mohr et al., 2011 [126],

USA,

Quantitative

To test the hypothesis that aggregate job satisfaction of individuals comprising primary care teams is positively associated with quality of care, using a multilevel framework that nests patients within teams and examines both preventive measures of quality and biological markers

Secondary data analysis using the VA External Peer Review Program (EPRP) database for patient-level quality-of-care scores and the 2007 VA All Employee Survey (AES) for health care team member ratings of job satisfaction

Primary Care Teams

Physicians,

mid-level providers, nurses, and support staff who have

responsibility for a defined panel of patients

Aggregate team member satisfaction ratings were positively associated with higher scores for both process and intermediate outcome quality measures in a primary care setting. Team member satisfaction was found to be a robust predictor, as it was associated with both process and intermediate outcome quality measures. The parameter estimate for aggregate team member satisfaction was significant, albeit modest, when regressed on measures of quality. Community outpatient clinics were negatively associated with intermediate outcome quality measures compared to parent medical facilities

Team-level job satisfaction ratings are a potentially important marker for the effectiveness of primary care teams in managing patient care

Enhance job resources or job characteristics, e.g., providing more job-related training, financial rewards, or allowing more participation in decision-making processes

Reduce job demands, e.g., allowing more time to complete job tasks, ensuring job roles and tasks are clear, or reducing workload by making changes or additions to staff

Mundt et al., 2015 [127], USA,

Quantitative

To evaluate the associations between primary care team communication, interaction, and coordination (ie, social networks); quality of care; and costs for patients with cardiovascular disease

Sociometric survey

Primary care clinics

155 health professionals from 31 teams at 6 primary care clinics

Teams with higher density of daily interactions (face to face) among all team members and lower centralization were associated with better quality of care. Specifically, teams with more members reporting daily interactions with a greater number of team members show better quality of care, as measured by a 38% reduction in hospital days and $516 less spent on average per patient in the previous 12 months. Team shared vision about goals and commitments mediated the connection between team social network structures and patient outcomes. In other words, dense daily team interactions with all team members, notably, face-to-face connections, contributed to the development of shared team vision on the team’s objectives and expectations, which was linked to better quality of cardiovascular disease care. Results indicate that neither individual professional excellence nor electronic health records solutions alone could produce desired improvements in quality of care

Primary care teams that are more interconnected and less centralized and that have a shared team vision are better positioned to deliver high-quality cardiovascular disease care at a lower cost

Future studies may wish to explore these variables further

Mundt et al., 2016 [128],

USA,

Quantitative

To determine whether primary care team communication and team climate are

associated with health outcomes, health care utilization, and associated costs for patients with diabetes

30-min face-to-face

structured questionnaire administered by a trained research assistant

Primary care clinics

Physicians,

physician assistants, or nurse practitioners

Primary care teams with a greater number of daily face-to-face communication ties

among team members were associated with 52% (Rate Ratio = 0.48, 95% CI: 0.22, 0.94) fewer

hospital days and US$1220 (95% CI: -US$2416, -US$24) lower health-care costs per team

diabetes patient in the past 12 months. In contrast, for each additional registered nurse who reported frequent daily face-to-face communication about patient care with the primary care practitioner, team diabetes patients had less-controlled HbA1c (Odds Ratio = 0.83, 95% CI: 0.66, 0.99), increased hospital days (RR = 1.57, 95% CI: 1.10, 2.03), and higher healthcare costs (β = US$877, 95% CI: US$42, US$1713). Shared team vision, a measure of team climate, significantly mediated the relationship between team communication and patient outcomes

Primary care teams which relied on frequent daily face-to-face communication among more team members, and had a single nurse communicating patient care information to the primary care provider, had greater shared team vision, better patient outcomes, and lower medical costs for their diabetes patient panels

Support face-to-face discussions, multiple times per day

Naccarella 2009 [129],

Australia,

Qualitative

To explore the types and the qualities of GP work-related relationships

Interviews

Primary health care

teams

General practitioners (GPs) practice nurses,

practice managers and receptionists

Four main types of GP work-related relationships emerged: clinical problem solving, obtaining

metaknowledge, obtaining legitimisation, and validation. Key qualities of GP work-related relationships included the nominated providers’ competence, accessibility, goodwill, honesty, consistency and communication styles

The study highlights the complex nature of GP work-related relationships that underpin the development of a primary health care system.

The types and qualities of work-related relationships could inform the way professional development programs build the skills of GP and other healthcare providers to develop relationships within multidisciplinary team-based care approaches.

The structure of GP working relationships and the context within which they are embedded are important considerations for policy reform aimed at influencing the healthcare system.

Policy emphasises should move from using structural reforms such as prescribed service delivery processes and financial incentives to encourage teamwork

Naccarella et al., 2013 [130], Australia,

Qualitative

To propose a framework to assist policymakers, educators, researchers, managers and health professionals in supporting team-based models of primary care within the Australian health care system

Literature

Primary care

Healthcare teams

A review of incentives for primary health care team service provision recommended, on the basis of limited evaluative evidence, that a key priority was to develop teamwork-focused evaluative tools and indicator sets. The review also suggested that investment was required in reviewing existing (international and Australian) teamwork-related, evidence-based, evaluative inventories, tools and methods for use in the Australian setting, as well as in developing and piloting a set of process and summative teamwork-evaluation indicators (at patient, provider, organisational, and systems levels) for use in the Australian setting

Current Australian health care policy reforms continue to emphasise team-based primary care, and the proliferation of team-based models and investments designed to sustain their implementation require a robust framework of support. The framework proposed is an evidence-informed way to assist policymakers, educators, researchers, managers and health professionals to support team-based models of primary care within the Australian health care system. The framework is to be followed as a recipe, without reflection; rather, it is as a set of ingredients to support the implementation and sustainability of team-based models of primary care

NR

Oandasan et al., 2009 [131], Canada,

Qualitative

To explore the impact of space and time on interprofessional teamwork in three primary health care centres and the implications for Canadian and other primary health care reform

Ethnographic observations; interviews

Academic family health centres

Three academic family health centres participated in a total of 139 hrs of observation and 37 interviews. Team members in all three centres from the disciplines of medicine, nursing, physiotherapy, occupational therapy, social work, dietetics, pharmacy, and office administration participated in this study

The study found that both the quantity and quality of interprofessional communication and collaboration in primary health care is significantly impacted by space and time. Across the three research sites, the physical layout of clinical space and the temporal organization of clinical practice led to different approaches to, and degrees of success with, interprofessional teamwork. Varied models of interprofessional collaboration resulted when these factors came together in different ways

The variability in team collaboration, which results from the interaction of temporal and spatial factors, has important implications for the transition of primary health care centres into Family Health Teams.ore likely to collaborate effectivel We found that providers in smaller interprofessional environments where providers are visible to one another and work from a reasonable proximity (not too far but not too close), are more interactive, both professionally and socially, and are more likely to collaborate effectively.

These findings have important implications for the transition to interprofessional family health teams in Canada and beyond

O’Brien et al., 2016 [132], Canada,

Qualitative

To add to knowledge regarding what components make up a high functioning interprofessional primary care team

Literature Review; Interviews; Focus groups

Primary care

Physicians, nurses, allied health members, administrative and leadership personnel

A practice environment where members of an interprofessional teamwork in close proximity (co-location) was seen as enabling team high functioning. Perceived benefits to patients of co-location included the ability of providers to deal concurrently and comprehensively with patients’ needs; a reduction in the number of missed appointments and referrals; more timely provision of care and reduced duplication of services. Co-location was also seen as providing benefits to providers including facilitated communication and collaboration and the creation of informal professional development opportunities

While this study focused on physician-led teams it was intended to stimulate a wider conversation about what makes for good primary care and effective teaming in a variety of settings

The process of learning from these high-functioning primary care teams can inspire the efforts of others, encourage reflection and spark new conversations about how to navigate the team improvement journey from good to great

Pereira and Oliveira, 2018 [133], Portugal,

Qualitative

To assess how Primary Health Care (PHC) nurses identify their professional autonomy in daily work and how this autonomy is perceived by other professionals of the multiprofessional team

Semi-structured interviews

Primary Health Care; Family Health Support Centres

27 nurses from the Family Health Strategy (FHS) and ten professionals from the Family Health Support Center

The findings revealed the professional autonomy of PHC nurses is perceived in the following categories: the possible autonomy, the autonomy dictated by protocols and the subordination to medical work

The study showed an expansion of the clinical scope of PHC nurses, and to a certain extent, it was closer to medical work. On the other hand, nurses are challenged to overcome such an approximation in the sense of interprofessional collaborative practice and advanced practice nursing

NR

Phipps-Taylor and Shortell, 2016 [134], USA,

Qualitative

To explore the types of motivators that leaders use to stimulate change within accountable care organizations (ACOs)

Semi-structured interviews

ACOs

Physicians

The case study ACOs more strongly emphasized non-financial motivators for changing physician behavior than financial incentives. These motivators included mastery and social purpose, which were used frequently across all case study sites. Overall, the ACO case studies illustrated variability across all motivational domains. While there was evidence of changing motivators as a result of the ACO, the case study ACOs found it difficult to comprehensively change the use of motivators, in part due to dispersed managerial attention and the complexity and diversity of programs and contracts that fragmented efforts to improve

Motivating behavior change within ACOs goes beyond financial incentives. ACOs are using a broad range of motivators, including creating ways to make a greater impact on patients and opportunities to be a more effective physician. Overall, it does not appear that ACOs are deploying the full range of available motivators

Develop more sophisticated and wider‐ranging portfolios of motivators to drive behavior change

Pullon et al., 2008 [135], New Zealand, Qualitative

To investigate the roles of nurses and doctors, as well as the relationships between nurses and doctors, in New Zealand primary care settings

In-depth interviews

Primary Care Settings

Nurses and doctors in primary care settings

Three primary domains of extrinsic factors affected relationships between nurses and doctors: organizational and funding structures of the health system, organizational and employment issues at the practice level, and training and education issues. Trust was also a major theme discussed by participants, especially in relation to respect

Relationships between nurses and doctors that are marked by trust are established in a sequential way between individuals

Highly functional interprofessional relationships have the potential to become the reality with active support at the health system, educational, and professional organization level

Pullon et al., 2009 [20], New Zealand,

Qualitative

To explore perceptions of interprofessional relationships, teamwork, and collaborative patient care in New Zealand primary care practice

In-depth interviews

Primary Care Practices

Individual nurses and doctors working in primary care settings

Nurses and doctors working in New Zealand primary care perceive funding models that include fee-for-service, task-based components as strongly discouraging collaborative patient care. In contrast, teamwork was seen to be promoted when health services, not individual practitioners, were bulk-funded for capitated healthcare provision. In well-organised practices, where priority was placed on uninterrupted time for meetings, open communication, and interprofessional respect, good teamwork was more often observed. Salaried practices, where doctors and nurses alike were employees, were considered by some interviewees to be particularly supportive of good teamwork

Health system, funding, and organisational factors act as significant barriers to the successful implementation of, and training for, effective teamwork in New Zealand primary care settings, despite new opportunities for more collaborative ways of working

More interprofessional education and professional development is needed to promulgate good business practice, and training in teamwork. It is essential that primary care nurses and doctors, as well as other primary healthcare professionals including pharmacists, physiotherapists, and midwives, are well-trained to work together, and well-supported to practice in effective teams

Pullon et al., 2016 [136], New Zealand,

Qualitative

To determine how interprofessional collaboration (IPC) is achieved and maintained in general practices

Field notes, video-recordings, and transcripts

General Practices

General practice teams

Five overarching and intersecting cross-case themes emerged as key elements of IPC at practice level, with each having helpful and challenging aspects. Three themes concerned contextual and organisational factors, and two represented factors intrinsic to people within practices and/or teams

In an “all of practice” approach, opportunities for major changes in physical space design or employment models only arise occasionally, but much organisational change is achievable where staff have shared goals. Multiple opportunities for frequent, often brief, shared interprofessional communication should be facilitated by as many routes as possible. Direct observational methods hold promise in furthering knowledge and understanding of IPC in primary care practice, with potential to make explicit the connections between organisational, spatial, and temporal elements and their relationship to interpersonal/intrinsic factors

Attention needs to be paid to intrinsic individual and team characteristics, organizational, physical, and community environment in which the primary care practice functions

Rioux-Dubois and Perron, 2021 [137], Canada,

Qualitative

To examine the integration and negotiation of the role of nurse practitioners in interprofessional primary healthcare settings

Semi-structured interviews (n = 23 nurse practitioners), direct observation, and document analysis

Community Health Centers (CHCs), Family Health Teams (FHTs), and NP-Led Clinics (PILCs)

Nurse practitioners, physicians

Organizational aims, practice standards, nurse practitioners’ right to self-determination, collaborative dynamics with physicians, and patient management were identified as integration factors that produced greater instability, needs for negotiation, and professional, identity, and moral difficulties for nurse practitioners

The results of this study challenge the commonly held belief that the role of nurse practitioners lacks clarity

Support flexible schedules, and role clarity for nurse practitioners

Rioux-Dubois and Perron., 2022 [138],

Canada,

Qualitative

To describe the enactment of interprofessional collaboration (IPC) in primary care settings, particularly as it relates to nurse practitioner (NP) integration

330 hrs of direct observation, 23 semi structured interviews, and document analysis

Community Health Centers (CHC), Family Health Teams (FHT), and Nurse Practitioner-Led Clinics (NPLC)

Physicians, nurses and nurse practitioners

The study shows that organizational care models with different mandates, strategic directions, remuneration models, and team sizes and composition, form parts of complex networks of human and non-human actors that give shape and meaning to IPC. Non-human actors, such as coffee machines and physical/virtual spaces, are active and powerful contributors to IPC. The study also shows that clinicians and managers could strengthen IPC by implementing administrative and clinical strategies that formalize IPC; defining IPC and its processes, and protecting time between collaborating partners

Organizational mandates and remuneration models, physical spaces and schedules played a decisive role in the enactment of IPC. Power structures embedded in certain designations (i.e., most responsible provider) or nurse practitioners commitments to physicians’ practices stood in contrast with the principles of IPC. Nurse Practitioners enacted various roles to develop, enhance, and maintain IPC. IPC remains poorly defined and precariously sustained

Both clinicians and managers should prioritize and carefully monitor the necessity and effective functioning of various forms of professional collaboration

Roland et al., 2006 [139], UK,

Mixed Methods

To describe initial changes and predict the consequences of general practice models of care that may follow from the introduction of quality incentives

Telephone semi-structured interviews; survey questionnaires

General Practice Clinics

General Practitioners (GPs)

GPs believed the new contract will have a positive affect on their quality of care in targeted areas but an adverse affect on their professional autonomy and work-load. There was little variation in this view across GPs with different demographic or practice characteristics

GPs believe the new contract will have a positive affect on their quality of care in targeted areas

NR

Rosenthal et al., 2005 [140], USA,

Quantitative

To evaluate the impact of a prototypical physician pay-for-performance program on quality of care

Reports analysis

Physicians

Physician groups

The findings give rise to a number of speculations about the effects of pay-for-performance. First, groups with baseline performance already above the targeted threshold understood that they needed only to maintain the status quo to receive the bonus payments. Low-performing groups improved as much as they did, given that their short-run chances of receiving the bonus were likely to be low. One possibility is that the groups viewed the quality improvement program as a larger signal of a changing environment in which they would face increasing pressure to improve their care systems and decided to begin moving in that direction. Paying explicitly for quality improvement might alter the incentives for high-performing and low-performing groups, distribute bonus dollars more toward the latter group, and possibly increase the overall impact of pay-for-performance

Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline

Continue experimentation with pay-for-performance

Russell et al., 2009 [141],

Canada,

Mixed Methods

(1) To assess whether chronic disease management differed among 4 models of primary health care delivery and (2) To identify which practice organizational factors were independently associated with high-quality care

Chart review, questionnaires, and semi-structured interviews

Community Health Centres (CHCs), Family Health Networks, Health Service Organizations

GPs and Nurse Practitioners

Chronic disease management was superior in CHCs. Clinicians in CHCs found it easier than those in the other models to promote high-quality care

through longer consultations and interprofessional collaboration. Across the whole sample and independent of the model, high-quality chronic disease management was associated with the presence of a nurse-practitioner. It was also associated with lower patient-family physician ratios and when practices had 4 or fewer full-time-equivalent family physicians

The study supports the value of nurse-practitioners within primary care teams and validates the contributions of Ontario's CHCs.

The observation that quality of care decreased in larger, busier practices suggests that moves toward larger practices and greater patient-physician ratios may have unanticipated negative effects on processes of care quality

Policy makers should support nurse-practitioners within primary care teams

As moves toward larger practices and greater patient-physician ratios may have unanticipated negative effects, focusing on optimizing smaller clinics may be beneficial

Savageau et al., 2016 [142],

USA,

Quantitative

To identify factors related to preparedness, recruitment and retention

Online survey of 170-items was sent to Primary care providers

Community health centers (CHCs)

Family medicine, internal medicine, pediatrics,

and obstetrics/ gynecology physicians

Beyond provider characteristics, several factors were important in retaining providers at CHCs. These factors included nonclinical interests in research and teaching, greater satisfaction with employee morale, the CHC model of care, recognition of clinical practice goals, professional development, and the availability of mentoring and feedback

The study suggests that CHCs should focus on factors such as mission, competency of peer physicians, teamwork, and supportive leadership in their recruitment and retention efforts. By addressing these factors, CHCs may be able to attract and retain providers who are committed to their mission and are satisfied with their work environment

Leaders should show interest in candidates who prioritize a shared mission and values

Opportunities to learn from peers should be prioritized

Schadewaldt et al., 2016 [143],

Australia,

Mixed Methods

To investigate the experiences and perceptions of nurse practitioners and medical practitioners who worked together under the new policies and aimed to identify enablers of collaborative practice models

Direct observations, documents and semi-structured, questionnaires

including validated scales

Collaborative practice models

Nurse practitioners, physicians, practice managers

Using the scale measurements, nurse practitioners and medical practitioners reported high levels of collaboration, were highly satisfied with their collaborative relationship and strongly believed that collaboration benefited the patient. The three themes developed from qualitative data showed a more complex and nuanced picture: 1) Structures such as government policy requirements and local infrastructure disadvantaged nurse practitioners financially and professionally in collaborative practice models; 2) Participants experienced the influence and consequences of individual role enactment through the co-existence of overlapping, complementary, traditional and emerging roles, which blurred perceptions of legal liability and reimbursement for shared patient care; 3) Nurse practitioners’ and medical practitioners’ adjustment to new routines and facilitating the collaborative work relied on the willingness and personal commitment of individuals

Findings of this study suggest that the willingness of practitioners and their individual relationships partially overcame the effect of system restrictions

Healthcare reform decision-makers should provide strategic support to enhance the roles of nurse practitioners and secure the long-term viability of collaborative practice models in primary healthcare

Shaw et al., 2005 [144], UK,

Qualitative

To see whether primary healthcare professionals in these practices felt that progress with Personal Medical Services (PMS) was underpinned by effective teamworking

Semi-structured interviews

Personal Medical Services practices

Primary care professionals

Some participants felt they had used PMS to build their teams and develop quality based patient care. For other practices teamworking was limited by the absence of a common goal, recruitment difficulties, inadequate communication and hierarchical structures, and prevented practices from moving forward with clear direction

The study indicates that changing the contractual arrangements does not necessarily improve teamworking. It highlights the need for more sustained educational and quality improvement initiatives to encourage greater collaboration and understanding between healthcare professionals

NR

Shortell et al., 2004 [145], USA,

Quantitative

To examine both the correlates of self-assessed or perceived team effectiveness and its consequences for actually making changes to improve care for people with chronic illness

Data analysis from program participation; Chronic Care Model (CCM)

Chronic Care Practices

Chronic Care team

A focus on patient satisfaction, the presence of a team champion, and the involvement of the physicians on the team were each consistently and positively associated with greater perceived team effectiveness. Maintaining a balance among cultural values of participation, achievement, openness to innovation, and adherence to rules and accountability also appeared to be important. Perceived team effectiveness, in turn, was consistently associated with both a greater number and depth of changes made to improve chronic illness care

The data suggest the importance of developing effective teams for improving the quality of care for patients with chronic illness

Research that examines patient physiological and patient satisfaction outcomes as a function of perceived team effectiveness and the number and types of changes actually made to improve care would further validate the importance of health care teams

Song et al., 2017 [146],

USA,

Mixed methods

To investigate the connections between team dynamics, job satisfaction of primary care providers (PCPs), and patient care coordination among PCPs in 18 primary care practices affiliated with Harvard that took part in Harvard's Academic Innovations Collaborative

Cross-sectional Survey and Qualitative Interviews

Primary Care Providers

Primary care physicians, nurse practitioners, and

physician assistants, and resident physicians

There was a significant correlation between positive team dynamics and high job satisfaction among PCPs. Better patient care coordination was linked to higher levels of job satisfaction among PCPs. The study also revealed that patient care coordination mediated the relationship between team dynamics and job satisfaction of PCPs

To improve the overall functioning of a primary care team, it is essential to focus on enhancing work processes such as accountability, communication, information exchange, and conflict resolution. These are the areas with the lowest average level in terms of team dynamics. If a team is formed without proper planning, these crucial elements may be overlooked, leading to less than optimal team dynamics

It is important that healthcare leaders focus on improving primary care team dynamics

Taylor et al., 2015 [147], USA,

Quantitative

To describe the implementation and impacts of Comprehensive Primary Care over its first year

Data feedback; the amount and format of feedback provided in other payers’ reports varied widely within regions

Comprehensive Primary Care (CPC) that involves 1) access and continuity, (2) planned chronic and preventive care, (3) risk-stratified care management, (4) patient and caregiver engagement, and (5) coordination of care across the medical neighborhood

Physicians, nurse practitioners, and physician assistants

This practice brought together 31 distinct payers (ranging from 3 to 9 per region) to collaborate in providing non-visit-based monthly care management fees, in addition to traditional payments, to support practices in their efforts to redesign and transform care. In the initial program year of CPC, this funding accounted for approximately 19 percent of total practice revenue (excluding CPC) or around $70,045 per clinician. Furthermore, CPC offers learning activities and data feedback on cost, service utilization, care quality, as well as patient, provider, and staff experiences to aid practices in their transformation journey. While there is room for improvement in learning activities and data feedback, ongoing refinements are being made. At the end of the first year, the majority of practices successfully achieved the required milestones, with fewer than 10 percent being placed on corrective action plans (38 practices) or terminated from the initiative (4 practices). Practice participation has remained stable, considering the substantial workload required to meet CPC's annual milestones. Payer participation has also shown consistency, with only a few payers discontinuing their involvement, and these payers had relatively small numbers of attributed patients in CPC

There was a notable but not statistically significant decrease (4 percent) in unplanned 30-day readmissions across the CPC program. However, there were limited significant effects observed on other quality-of-care outcomes or process measures assessed, which reflect the care provided by all healthcare providers involved in treating the patients

Policymakers should support learning about team-based care

Unützer et al., 2012 [148], USA,

Quantitative

To evaluate a quality improvement program with a pay-for-performance (P4P) incentive in a population-focused, integrated care program for safety-net patients in 29 community health clinics

Quasi-experimental design, data analysis

Community health clinics

Patients

The analysis suggests that the institution of a quality improvement program with a P4P incentive substantially improved the quality and outcomes of care provided by the program. After the institution of the P4P incentive program, participants were substantially more likely to experience a significant improvement in depression severity, and the time to improvement was dramatically reduced compared with before the P4P incentive was implemented. These improvements in clinical outcomes were consistent with improvements observed in the quality of care that were the intended aims of the P4P initiative, such as early follow-up and psychiatric consultation for patients who were not improving

When clinical outcomes and key quality indicators are routinely tracked and a substantial portion of the payment for care is tied to quality indicators such as adequate follow-up and consultation for patients who are not improving, the quality and effectiveness of such programs can be substantially improved

NR

Valentijn et al., 2015 [149],

Canada,

Mixed methods

1) To develop a typology of integrated care projects (ICPs) based on the final degree of integration as perceived by multiple stakeholders. 2) To study how types of integration differ in changes of collaboration processes over time and final perceived effectiveness

Surveys and interviews

Integrated care projects

General practitioners, nurse, social

worker and allied health professionals

ICPs within the United Integration Process subgroup made the strongest increase in trust-based (mutual gains and relationship dynamics) as well as control-based (organisational dynamics and process management) collaboration processes and had the highest overall effectiveness rates. ICPs with the Disunited Integration Process subgroup decreased on collaboration processes and had the lowest overall effectiveness rates. ICPs within the Professional-oriented Integration Process subgroup increased in control-based collaboration processes (organisational dynamics and process management) and had the highest effectiveness rates at the professional level

The research indicates that effective collaboration processes among stakeholders lead to shared perspectives and higher rates of effectiveness over time. On the other hand, when there are divergent perspectives at the professional, organizational, and system levels, trust-based and control-based collaboration processes can help align these perspectives. The study underscored the significance of acknowledging diverse viewpoints and employing various collaborative approaches when designing and implementing integrated care initiatives to achieve favorable outcomes

Healthcare leaders should focus on cultivating trust

Future research should explore the need of relational trust- versus transactional control-based collaboration mechanisms

Beales et al., 2011 [150], Canada,

Qualitative

To improve interprofessional collaboration on family health teams (FHTs) and other evolving healthcare teams, by examining the effect of professional culture on FHT collaboration

In-depth semi-structured focus groups

Academic teaching hospital

Medicine, nursing, and allied health professions at the Family Health Centre and Diabetes Education Centre in a large academic teaching hospital

Three main themes emerged: professional culture; FHT culture; and resources. Professional culture cannot be neatly separated from one’s personal, social or professional history, which ties in with opinions of accountability, power and hierarchy. Structure and processes of the FHT that encourage collaborative processes; clearly articulated scopes of practice, skills, authority; clarifications of roles and responsibilities; and opportunities to develop team relationships are necessary to diffuse the tension that exists between professional and FHT cultures

FHTs are multidisciplinary groups co-located but with a lack of meaningful structures and processes to support collaboration. There is heavy physician dominance and physicians seem to adhere to old hierarchical structures and beliefs, consistent with their professional culture

Health care providers need to build collaborative competencies (e.g. role clarity, effective communication) to move a group of interdisciplinary health care providers toward being a highly performing interprofessional team

Wilson et al., 2005 [151],

Canada,

Mixed methods

To assess Canadian family physicians/ general practitioners’ (FPs/GPs) interest and involvement in interdisciplinary collaborative practice

Focus groups and survey

Interdisciplinary collaborative practice

FP/GP, nurse practitioners, pharmacist, others

In focus groups, FPs/GPs identified seven categories of issues related to interdisciplinary collaborative practice: quality and capacity of care, quality of

work life, affordability, availability/accessibility of other health professionals, team-building processes, responsibility/accountability, and system resources. Survey responses from 300 of 583 FPs/GPs in the region (51%) showed substantial interest in working with other health professionals, but strikingly less frequent current working relationships

The large gap between the interest and willingness of FPs/GPs to collaborate and their current involvement in teamwork must be addressed if collaborative practice is to increase in line with the goals of primary care reform in Canada

Policy makers should close the gap between the interest and willingness of FPs/GPs to collaborate and their current involvement in teamwork

Wranik et al., 2017 [48],

Canada,

Qualitative

To develop a framework for the conceptualization and analysis of financial arrangements in interdisciplinary primary care teams

(i) Interviews with 19 primary care decision makers representing 215 clinics in three Canadian provinces, (ii) A research roundtable with 14 primary care decision makers and/or researchers, and (iii) policy documents

Interdisciplinary Primary Care Teams (IDPC Teams)

Physicians, nurses and other non-physicians

Emergent implementation issues discussed by respondents include: (i) centrality of budget negotiations; (ii) approaches to patient rostering; (iii) unclear funding sources for space and equipment; and (iv) challenges with community engagement

The identification of optimal financial arrangements must be contextualized in terms of feasibility and the implementation environment. Financial hierarchy, both overt and covert, is considered a barrier to collaboration

Future research must explore the interplay between financial and non-financial incentives

Team funding should not just be tied to physician activities

Wranik et al., 2018 [152],

Canada,

Qualitative

To characterize the implications that financial arrangements have on the balance of power in teams and whether financial models were perceived to influence the presence of professional hierarchies

(i) Policy documents

describing financial/remuneration models in Interdisciplinary Primary Care (IDPC) teams across Canada, (ii) Semi-structured interviews

Primary care networks

Medical doctors, nurses, and other health care

providers across three provinces

The study found that fee-for-service funding models were associated with medical dominance in interdisciplinary primary care teams, as the physicians in these models held decision-making power and controlled the distribution of resources. Salary-based funding models were found to facilitate more equitable decision-making and resource allocation within interdisciplinary primary care teams. These models allowed for increased collaboration and teamwork among healthcare providers

The fee-for-service model was associated with higher medical dominance, while salary-based models facilitated more equitable decision-making and resource allocation within teams

Policymakers should implement policies that minimize financial hierarchies and streamline funding sources

Xyrichis et al., 2008 [153], UK,

Qualitative

To explore factors that inhibit or facilitate interprofessional teamworking in primary and community care settings

Comprehensive review of quan/qual studies

Primary and community care settings

Primary care teams

Two main themes emerged that had an impact on interprofessional teamworking: team structure and team processes. Within these two themes, six categories were identified: team premises; team size and composition; organisational support; team meetings; clear goals and objectives; and audit. The complex nature of interprofessional teamworking in primary care meant that despite teamwork being an efficient and productive way of achieving goals and results, several barriers exist that hinder its potential from becoming fully exploited; implications and recommendations for practice are discussed

These findings can inform development of current best clinical practice

Further research needs to be conducted into multidisciplinary teamworking at both the team and organisation level, to ensure that enhancement and maintenance of teamwork leads to an improved quality of healthcare provision