2D: BUILDING STRONGER TEAMS AT YOUR HEALTH CENTRE

1. Building stronger teams at your
Health Centre
Jennifer Rayner
Laura Muldoon
Canadian Association of CHCs
September 18, 2015

3. Team Functioning...good and bad
teams?
 Describe well-
functioning and not
well-functioning
teams.
 What causes teams
to function poorly?

4. Details
 COI - Investigators are employees of CHCs
 Funding from University of Ottawa
Department of Family Medicine Research
Funding Program
 Ethics from Ottawa Health Sciences
Research Network and Bruyère Continuing
Care

5. What are PC teams?
 Inter-professional teamwork in
PHC is a priority in Canada2
 Know more about who team
members are than what they
do or how they work together.3
 Membership of PC teams vary
widely depending on the
setting2
 Care is by “the integrated
activities of clinical and non-
clinical members of (PC)

6. What is team function?
“Team function (the
processes and psycho-
social traits of the team)
links a team’s task design
(types & features of the
tasks, team members) to
its effectiveness”

7. Is team function important?
 linked to innovation and
effectiveness in PC ,
technical quality of care.
 may have more influence
over clinical behaviors in PC
than individual provider or
practice characteristics.8
 can be improved by certain
interventions.9

8. Why look at CHC teams?
 Quality of primary care equivalent or superior
to that in other PC models in Ontario.2, 11,12,13
 ICES – CHC study
 “If you’ve seen one CHC, you’ve seen one
CHC”
 Provincial tour – different “feel” to the teams
 Little is known about CHC PC team function
 Quebec community-governed practices
(some similar to Ontario CHCs) had lower
scores for team climate than professionally-
14

9. Previous Research Results
 Staff Groups & Teams
 Ontario: admin staff reported
“suboptimal” team climate more than
GPs.14
 US CHC physicians dissatisfied with
high workloads and administrative
management.15,16
 No literature on how other team
members view team functioning
 Organizational Features & Teams
 Leadership, professional
governance, solo practice, certain
team cultures are associated with
better team function
 No association previously found with
size of the team or number of sites

10. Our Questions...
 How do CHC staff rate the
functioning of their teams?
 Are there differences
between different groups of
staff in how team function is
perceived?
 Are there differences
between different CHC
organizations?
 Are there organizational

11. Methods
 Cross-sectional, part of proposed larger
study
 Ethics – OHSRN/Bruyère REB
 All 75 CHCs invited
 PHC director completed organizational
survey
 ED distributed on-line survey to PC staff
 “any person who provided or supported the
provision of clinical care on a regular basis”
(including administration & reception)

12. Organizational Survey
 Adapted from CIHI
 Number of sites, staffing,
size, priorities, means of
communication, rurality,
years of operation,
patient demographics

13. Staff Survey
 Descriptive
(professional role, full-
time status, number of
years employed at the
CHC , working off-site
from the main clinic)
 3 different scales

14. Team Climate Inventory
 Team Climate:
shared perceptions
of policies, practices
& procedures within
team
 Short, validated 14
item version
Vision
 Innovation
 Participative
safety

15. Organizational Justice
 Assesses perceptions of fairness, equity &
respect
 Procedural Justice (PJ) – 7 items (perceived
fairness)
“Procedures are in place to generate
standards so that decisions can be made
with consistency”
 Interactional Justice (IJ) – 6 items
(politeness, dignity & respect)
 “Primary health care team members

16. Organizational Citizenship Behaviour
 Perceptions of the presence of work
related behaviors that are:
discretionary
not related to the formal reward system
in the aggregate promote the effective
functioning of the organization.20
 13 items
 “Help each other out if someone falls
behind in his/her work”

17. Analysis
Staff characteristics
 Responses stratified by staff group
(manager, physician, NP, registered nurse,
medical secretary, allied health, counselor,
outreach, admin assistants)
 One-way Anova to determine overall
difference in team climate, organizational
justice and citizenship behaviour between
the different provider groups.
 Bonferroni posthoc analysis based on apriori
hypothesis
Organizational characteristics

18. Overall Results
 58 CHCs (77.8%)
 674 staff (approx. 60%)
 physicians, NPs, nurses
–
 57% of the respondents
 Excluded “system
navigators” due to low
numbers

19. 0
10
20
30
40
50
60
70
80
90
100
NP MD Nurse SW Allied Out MOA AA Mgr
%
CHC Staff (Ontario)
Yrs x10
FT (%)

20. Results – Staff characteristics
 One way ANOVA –
significant difference
between staff groups on
mean scores for:
Procedural Justice (p=
0.01)
Total TCI (p=0.03)
 Innovation subscale of
TCI (p=0.011)

21. Team Climate Inventory
4.6
4.7
4.8
4.9
5
5.1
5.2
5.3
5.4
5.5
5.6

22. Organizational Justice
4.2
4.4
4.6
4.8
5
5.2
5.4
5.6

23. Organizational Citizenship Behaviour
4.7
4.8
4.9
5
5.1
5.2
5.3
5.4

24. Differences between groups
 NPs and FPs rated Procedural Justice statistically
significantly lower than nurses, managers,
secretaries and admin assistants (p<.05)

25. Mean (sd)/% Median Range
Years of operation 19.1 (12.5) 21 3-50
Number of primary health care staff 17.7 (10.5) 14.3 2.6-65
Number of Sites 2.5 (1.7) 2.0 1-7
Primary care providers ratio to other staff 50.0 (16.9) 48.4 23.7-100
Priority population based (%) 45.6
Rural location (%) 17.5
CHCs that ranked team as an organizational priority (%) 19
PHC team attend meetings (%) 70.2
Total Team Climate Inventory (TCI) 5.3 (.5) 5.4 3.9-6.2
TCI - Vision 5.5 (.9) 5.8 1.5-7.0
TCI - Task orientation 5.1 (1.3) 5.0 1.5-7.0
TCI - Support for innovation 5.1 (1.3) 5.3 1.0-7.0
TCI - Participative safety 5.5 (1.2) 5.3 1.0-7.0
Total Organizational Justice (OJ) 5.1 (.55) 5.1 3.6-6.2
OJ - Procedural justice 4.7 (.74) 4.9 2.4-6.0
OJ - Interactional justice 5.5 (.52) 5.5 4.2-6.5
Organizational Citizenship Behaviours 5.1 (.46) 5.0 3.1-6.0
Organizational Characteristics

26. PJ - Organizational level results

27. Organizational features & team function
 Association ONLY
between higher
number of sites,
being located in an
urban area and lower
team function. (TCI
and OJ p<0.05)
 The different
measures of team
function were highly
correlated at the

28. 0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
PJ
IJ
OJTCI
OCB
PJ
IJ
OJ
TCI
OCB

29. Discussion
 TCI ratings similar to other Canadian PC studies.7,21
 OCB, OJ lower end of range of results reported in
other settings.8,22, 23
 Staff in each CHC tended to rate their CHC
similarly on all the scales
 Differences between staff types for TCI,
“innovation” and PJ
 Different expectations?
 TCI link to patient-reported access, continuity,
quality of diabetes care, patient satisfaction,
technical quality of care BUT not in every study.

30. Procedural Justice
 NPs & physicians significantly lower than admin
staff & nurses
 PJ linked to improved quality of diabetes care8,
better glycemic control 22 more job satisfaction
among physicians and nurses 26,27
 Perceived injustice linked with poorer quality,
lower productivity of health care work 28,29
stress-related disorders among staff30

31. Why the different PJ ratings?
 CHC model – managers manage  Providers
don’t
 NP and FP have different expectations?
 NP unhappy about division of labour on team?
 NP unhappiness about wages?
 FP more part time. (PT staff rate team higher,
more resistant to change24,25 )
 Longer duration of employment (FP) – effect?
 Medical secretaries left many questions
unanswered – questions too clinical? Or didn’t
feel they were part of the team?

32. Organizational features
 CHCs have many organizational features in common
 community governance
 inter-professional teams
 model for remunerating staff
 leadership model
 Staff of a team spread across many sites may not
feel cohesive (Future: assess as separate entities the
“teamlets” that make up multi-site teams.)
 Many differences between urban and rural
communities, health care, health care teams

33. Strengths/Weaknesses
 77% CHCs participated
 Lots of staff – BUT no exact denominator
 Validated instruments

34. Conclusion
 All staff had positive ratings of team climate,
organizational justice and organizational
citizenship behaviours
 FPs and NPs had lower ratings for procedural
justice.
 Procedural Justice has been shown to be very
important in other settings, and may be amenable
to improvement through interventions.
 The only Org features relating to function were
number of sites and urban location

35. Next steps
 Qualitative study
 Will choose high and low
performing sites for
interviews
 Staff of different types
will be interviewed

36. Qualitative Study Questions
 We will be exploring the causes of lower PJ
ratings among physicians and NPs
Is there a systemic cause of lower PJ?
Are there specific aspects in their
organization that physicians and NP find
unjust – are these ongoing?
If there are systemic causes, are these
causes rectifiable, or are they inherent in
the CHC model?
What changes could be made within the

37. Previous Research Results - Conflict
 Main sources of conflict
Role boundaries, scope of practice &
accountability
 Barriers to conflict
Time/workload, power, recognition,
avoidance
 Strategies
Team strategies – conflict resolution
protocols, reliance on leadership to
negotiate conflict

38. Previous research results – factors
that contribute to positive teamwork
 Team Structure
Team premises
Size and composition of
team
Leadership
Stability
Organizational Support
 Team Processes
Team meetings
Clear team goals

39. What do you think?
 Jane is the manager of a
PHC team at a CHC. Their
regional health authority has
implemented a new
performance measure
targeting primary care panel
size.
 The target that has been set
for the CHC will necessitate
that the primary care team
(MD and NPs) take on many
more new patients.

40. jrayner@lihc.on.ca
lmuldoon@swchc.on
.ca

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