Integrated Place-Based Primary Interventions: Levers and Tensions Related to Multilevel Governance for Community Integrated Pathways, A Multiple Case Study.

Integrated Place-Based Primary Interventions (IPPIs) are considered an innovative response to the challenges and complex issues faced in disadvantaged areas where traditional institutional services have difficulty reaching people in vulnerable situations. IPPIs are an innovative approach to the delivery of in services, conceived as an original community-based local care and service pathways. However, these intervention practices require adaptive modes of governance. In this article, we explore how and to what extent the mode of governance of IPPIs influences the performance of community-integrated pathways. To this end, using a qualitative exploratory multiple-case study design (observation and semi-structured interviews), we describe 4 IPPIs in 3 territories in Quebec. This includes an examination of the levers of action and tensions related to their governance and the performance levels of the community-integrated pathways. We conclude that collaborative and shared multilevel governance, despite its demanding nature, appears to contribute to the longevity of the actions and benefits of IPPIs and could prevent their relevance from being questioned.

Comparing the implementation of advanced access strategies among primary health care providers.

The advanced access (AA) model is among the most recommended innovations for improving timely access in primary health care (PHC). Originally developed for physicians, it is now relevant to evaluate the model's implementation in more interprofessional practices. We compared AA implementation among family physicians, nurse practitioners, and nurses. A cross-sectional online open survey was completed by 514 PHC providers working in 35 university-affiliated clinics. Family physicians delegated tasks to other professionals in the team more often than nurse practitioners (p = .001) and nurses (p < .001). They also left a smaller proportion of their schedules open for urgent patient needs than did nurse practitioners (p = .015) and nurses (p < .001). Nurses created more alternatives to in-person visits than family physicians (p < .001) and coordinated health and social services more than family physicians (p = .003). During periods of absence, physicians referred patients to walk-in services for urgent needs significantly more often than nurses (p = .003), whereas nurses planned replacements between colleagues more often than physicians (p <.001). The variations among provider categories indicate that a one-size-fits-all implementation of AA principles is not recommended.

Taxonomy of advanced access practice profiles among family physicians, nurse practitioners and nurses in university-affiliated team-based primary healthcare clinics in Quebec.

OBJECTIVES: The advanced access model is highly recommended to improve timely access to primary healthcare (PHC). However, its adoption varies among PHC providers. We aim to identify the advanced access profiles of PHC providers. DESIGN: A cross-sectional study was conducted between October 2019 and March 2020. Latent class analysis (LCA) measures were used to identify PHC provider profiles based on 14 variables, 2 organisational context characteristics (clinical size and geographical area) and 12 advanced access strategies. SETTING AND PARTICIPANTS: All family physicians, nurse practitioners and nurses working in the 49 university-affiliated team-based PHC clinics in Quebec, Canada, were invited, of which 35 participated. PRIMARY OUTCOME MEASURE: The LCA was based on 335 respondents. We determined the optimal number of profiles using statistical criteria (Akaike information criterion, Bayesian information criterion) and qualitatively named each of the six advanced access profiles. RESULTS: (1) Low supply and demand planification (25%) was characterised by the smallest proportion of strategies used to balance supply and demand. (2) Reactive interprofessional collaboration (25%) was characterised by high collaboration and long opening periods for appointment scheduling. (3) Structured interprofessional collaboration (19%) was characterised by high use of interprofessional team meetings. (4) Small urban delegating practices (13%) was exclusively composed of family physicians and characterised by task delegation to other PHC providers on the team. (5) Comprehensive practices in urban settings (13%) was characterised by including as many services as possible on each visit. (6) Rural agility (4%) was characterised by the highest uptake of advanced access strategies based on flexibility, including adjusting the schedule to demand and having a large number of open-slot appointments available in the next 48 hours. CONCLUSION: The different patterns of advanced access strategy adoption confirm the need for training to be tailored to individuals, categories of PHC providers and contexts.

Learning from intersectoral initiatives to respond to the needs of refugees, asylum seekers, and migrants without status in the context of COVID-19 in Quebec and Ontario: a qualitative multiple case study protocol.

BACKGROUND: Refugees, asylum seekers, and migrants without status experience precarious living and working conditions that disproportionately expose them to coronavirus disease 2019 (COVID-19). In the two most populous Canadian provinces (Quebec and Ontario), to reduce the vulnerability factors experienced by the most marginalized migrants, the public and community sectors engage in joint coordination efforts called intersectoral collaboration. This collaboration ensures holistic care provisioning, inclusive of psychosocial support, assistance to address food security, and educational and employment assistance. This research project explores how community and public sectors collaborated on intersectoral initiatives during the COVID-19 pandemic to support refugees, asylum seekers, and migrants without status in the cities of Montreal, Sherbrooke, and Toronto, and generates lessons for a sustainable response to the heterogeneous needs of these migrants. METHODS: This theory-informed participatory research is co-created with socioculturally diverse research partners (refugees, asylum seekers and migrants without status, employees of community organizations, and employees of public organizations). We will utilize Mirzoev and Kane's framework on health systems' responsiveness to guide the four phases of a qualitative multiple case study (a case being an intersectoral initiative). These phases will include (1) building an inventory of intersectoral initiatives developed during the pandemic, (2) organizing a deliberative workshop with representatives of the study population, community, and public sector respondents to select and validate the intersectoral initiatives, (3) interviews (n = 80) with community and public sector frontline workers and managers, municipal/regional/provincial policymakers, and employees of philanthropic foundations, and (4) focus groups (n = 80) with refugees, asylum seekers, and migrants without status. Qualitative data will be analyzed using thematic analysis. The findings will be used to develop discussion forums to spur cross-learning among service providers. DISCUSSION: This research will highlight the experiences of community and public organizations in their ability to offer responsive services for refugees, asylum seekers, and migrants without status in the context of a pandemic. We will draw lessons learnt from the promising practices developed in the context of COVID-19, to improve services beyond times of crisis. Lastly, we will reflect upon our participatory approach-particularly in relation to the engagement of refugees and asylum seekers in the governance of our research.

Nursing practice and teleconsultations in a pandemic context: A mixed-methods study.

AIM: To explore the use and implementation of teleconsultations by primary care nurses in the context of the COVID-19 pandemic. BACKGROUND: Teleconsultation use increased rapidly during the COVID-19 pandemic. Its implementation has been documented for physicians and specialists, but knowledge is still limited in nursing practice. DESIGN: A sequential mixed-methods study. METHODS: Phase 1: A cross-sectional e-survey with 98 nurses (64 nurse clinicians [NCs] and 34 nurse practitioners [NPs]) was conducted in 2020 in 48 teaching primary care clinics in Quebec (Canada). Phase 2: Semi-structured interviews with four NCs and six NPs were conducted in 2021 in three primary care clinics. This study adheres to STROBE and COREQ guidelines. RESULTS: During the pandemic, telephone was the principal teleconsultation modality used by NPs and NCs compared to other teleconsultation modalities (text messages, email and video). The only variable associated with a higher likelihood of using teleconsultations was type of professional (NCs). Video consultation was almost absent from the modalities used. The majority of participants reported several facilitators to using teleconsultations in their work (e.g. web platforms and work-family balance) and for patients (e.g. rapid access). Some barriers to utilisation were identified (e.g. lack of physical resources) for successful integration of teleconsultations at the organisational, technological and systemic levels. Participants also reported positive (e.g. assessment of cognitive deficiency) and negative (e.g. rural population) impacts of using teleconsultations during a pandemic that made the use of teleconsultations complex. CONCLUSION: This study highlights the potential for nurses to use teleconsultations in primary care practice and suggests concrete solutions to encourage their implementation after the pandemic. RELEVANCE TO CLINICAL PRACTICE: Findings emphasize the need for updated nursing education, easy-to-use technology and the strengthening of policies for the sustainable use of teleconsultations in primary health care. IMPLICATIONS FOR THE PROFESSION: This study could promote the sustainable use of teleconsultations in nursing practice. REPORTING METHOD: The study adhered to relevant EQUATOR guidelines; the STROBE checklist for cross-sectional studies and the COREQ guidelines for qualitative studies were used for reporting. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution, as the study focused on the use of teleconsultation among health professionals, specifically primary care nurses.

Measuring the Optimal Time Interval Between Arrival and First Mental Health Evaluation's for Refugees in Québec: A Scoping Review.

To map the state of the existing literature to identify the optimal time frame between the arrival of refugees in a host country and psychosocial assessments. We conducted scoping review using the method of Arksey and O'Malley (2005). A systematic search of 5 databases including PubMed, Psycinfo (OVID), PsycINFO BD APA, Scopus and Web of Sciences) and grey literature identified 2698 references. Thirteen studies published between 2010 and 2021 were considered eligible. A data extraction grid was designed and tested by the research team. It is not so ease to identify the most appropriate time interval to assess the mental health of newly settled refugees. All the studies selected agree on the need to carry out an initial assessment when refugees arrive in their host country. Several authors agree on the need to carry out screening at least twice during the resettlement period. However, what is less clear is the best time to perform the second screening. This scoping review mainly helped in highlighting the lack of probing data on the mental health indicators focused on during the assessment and on the optimal timeline for the assessment of refugees. Further research is needed to determine whether developmental and psychological screening is beneficial, the right time to perform the screening, and the most appropriate collection instruments and interventions.

Journey Through the Fractalization of Multilevel Governance: Levers for Adapt Healthcare Organizations Toward Migrant Populations in Canada.

This article focuses on multilevel governance applied to health organizations in Québec (Canada). The objective is to understand the action levers that facilitate the adaptation of the services toward migrant populations. This type of population establishes itself as an excellent tracer case to analyze the adaptation process, its fractalization and its involvement with the Environment. The dynamics between the actors and their self-organization takes part in the development of a multilevel governance. Interactions with the Environment-both internal and external-highlight the development of networks that emerge from the field and are then implemented at strategic levels in the organizations. The presence of connectivity actors within the organization and the Environment is established. The context, the bonds of trust between the actors and the credibility of the policymakers are reflected as important factors. However, connectivity actors cannot be successful without the support and contribution of the more "hierarchical" actors. Eight action levers are revealed by the analysis. We categorized them in 3 functions: administrative, enabling, and emerging. The levers of the administrative and emerging functions require that the levers of the enabling function be credible and legitimate and be able to support them for the adaptation to spread throughout the healthcare organization, regardless of the scope or policymaking level. The fractal function facilitates this process, by combining connectivity actors with the implementation of connectivity structures.

Revising the advanced access model pillars: a multimethod study.

BACKGROUND: The advanced access model was developed 20 years ago and has been implemented in several countries. We aimed to revise and operationalize the pillars and subpillars of the advanced access model based on its contemporary practice by professionals in primary health care. METHODS: This multimethod sequential study was informed by a literature review and an expert panel of provincial and local decision-makers, primary health care clinic members (family physicians, nurses and administrative staff), patients and researchers from the province of Quebec. Throughout the consultation process, participants were asked to develop a common vision of the pillars and subpillars that make up the advanced access model and to react to suggested definitions or content. RESULTS: The revised advanced access model is defined by 5 pillars, of which 2 were updated from the original model ("Appointment system" and "Interprofessional practice"), 1 was merged with a revised pillar ("Develop contingency plans" with "Planning of needs and supply") and 1 underwent major transformations ("Backlog reduction" to "Continuous adjustment"). A new pillar concerning communication emerged from the consultation process. Subsequent steps for operationalizing definitions of subpillars confirmed the nature of the revised advanced access pillars and stabilized their content. INTERPRETATION: The overall consultation process resulted in a revised contemporary advanced access model, with strong consensus among participating experts. The revised model will be used to develop a reflective tool for primary health care professionals to evaluate their advanced access practice.

Development of a self-reported reflective tool on advanced access to support primary healthcare providers: study protocol of a mixed-method research design using an e-Delphi survey.

INTRODUCTION: Timely access is one of the cornerstones of strong primary healthcare (PHC). New models to increase timely access have emerged across the world, including advanced access (AA). Recently in Quebec, Canada, the AA model has spread widely across the province. The model has largely been implemented by PHC professionals with important variations; however, a tool to assess their practice improvement within AA is lacking. The general objective of this study is to develop a self-reported online reflective tool that will guide PHC professionals' reflection on their individual AA practice and formulation of recommendations for improvement. Specific objectives are: (1) operationalisation of the pillars and subpillars of AA; (2) development of a self-reported questionnaire; and (3) evaluation of the psychometrics. METHODS AND ANALYSIS: The pillars composing Murray's model of AA will first be reviewed in collaboration with PHC professional and stakeholders, patients and researchers in a face-to-face meeting, with the goal to establish consensus on the pillars and subpillars of AA. Leading from these definitions, items will be identified for evaluation through an e-Delphi consultation. Three rounds are planned in 2020-2021 with a group of 20-25 experts. A repository of recommendations on how to improve one's AA practice will be populated based on the literature and enriched by our experts throughout the consultation. Median and measures of dispersions will be used to evaluate agreement. The resulting tool will then be evaluated by PHC professionals for psychometrics in 2021-2022. ETHICS AND DISSEMINATION: The Centre Intégré de Santé et de Services Sociaux de la Montérégie-Centre Scientific Research Committee approved the protocol, and the Research Ethics Board provided ethics approval (2020-441, CP 980475). Dissemination plan is a mix of community diffusion through and for our partners and to the scientific community including peer-reviewed publications and conference presentations.

Implementation of an intersectoral outreach and community nursing care intervention with refugees in Quebec: A protocol study.

AIM: To establish and assess an intersectoral local network focused on the roles of registered nurses and primary healthcare nurse practitioners to ensure the continuity of care and service pathways for refugees in Quebec. DESIGN: Developmental evaluation with a mixed methodology. METHODS: The qualitative component will include: (1) a document review; (2) observations of participants during meetings of different governance structures; (3) semi-structured interviews with key actors (n = 40; 20/neighbourhood interventions); and (4) focus groups with end users of the services (refugees) (n = 4; 6 to 8 participants per group). The quantitative component will be based on: (1) a data sheet on health and social interventions for refugees users filled in by registered nurses, primary healthcare nurse practitioners and physicians and (2) data analysis of the clinical-administrative database since 2012. This study received funding in June 2019 and Research Ethics Committee approval was granted in July 2020. DISCUSSION: In Quebec, refugee vulnerability is exacerbated by the lack of integration of existing resources and the lack of access to care and continuity of services. To address these issues, an integrated local network for refugees must be developed. Additionally, we will explore the role of registered nurses and their collaboration with primary healthcare nurse practitioners. IMPACT: This study will provide recommendations on how to optimize the scopes of practice of registered nurses and primary healthcare nurse practitioners, adapt care and services and develop a local intersectoral network to better meet the complex needs of refugees. It will evaluate the use and the appreciation of new services for targeted populations (neighbourhoods and refugees) and aim to improve the accessibility, continuity and user experience of all health services for those populations.

Interprofessional advanced access - a quality improvement protocol for expanding access to primary care services.

BACKGROUND: The Advanced Access (AA) Model has shown considerable success in improving timely access for patients in primary care settings. As a result, a majority of family physicians have implemented AA in their organizations over the last decade. However, despite its widespread use, few professionals other than physicians and nurse practitioners have implemented the model. Among those who have integrated it to their practice, a wide variation in the level of implementation is observed, suggesting a need to support primary care teams in continuous improvement with AA implementation. This quality improvement research project aims to document and measure the processes and effects of practice facilitation, to implement and improve AA within interprofessional teams. METHODS: Five primary care teams at various levels of organizational AA implementation will take part in a quality improvement process. These teams will be followed independently over PDSA (Plan-Do-Study-Act) cycles for 18 months. Each team is responsible for setting their own objectives for improvement with respect to AA. The evaluation process consists of a mixed-methods plan, including semi-structured interviews with key members of the clinical and management teams, patient experience survey and AA-related metrics monitored from Electronic Medical Records over time. DISCUSSION: Most theories on organizational change indicate that practice facilitation should enable involvement of stakeholders in the process of change and enable improved interprofessional collaboration through a team-based approach. Improving access to primary care services is one of the top priorities of the Quebec's ministry of health and social services. This study will identify key barriers to quality improvement initiatives within primary care and help to develop successful strategies to help teams improve and broaden implementation of AA to other primary care professionals.

Changing nursing practice within primary health care innovations: the case of advanced access model.

BACKGROUND: The advanced access (AA) model has attracted much interest across Canada and worldwide as a means of ensuring timely access to health care. While nurses contribute significantly to improving access in primary healthcare, little is known about the practice changes involved in this innovative model. This study explores the experience of nurse practitioners and registered nurses with implementation of the AA model, and identifies factors that facilitate or impede change. METHODS: We used a longitudinal qualitative approach, nested within a multiple case study conducted in four university family medicine groups in Quebec that were early adopters of AA. We conducted semi-structured interviews with two types of purposively selected nurses: nurse practitioners (NPs) (n = 6) and registered nurses (RNs) (n = 5). Each nurse was interviewed twice over a 14-month period. One NP was replaced by another during the second interviews. Data were analyzed using thematic analysis based on two principles of AA and the Niezen & Mathijssen Network Model (2014). RESULTS: Over time, RNs were not able to review the appointment system according to the AA philosophy. Half of NPs managed to operate according to AA. Regarding collaborative practice, RNs were still struggling to participate in team-based care. NPs were providing independent and collaborative patient care in both consultative and joint practice, and were assuming leadership in managing patients with acute and chronic diseases. Thematic analysis revealed influential factors at the institutional, organizational, professional, individual and patient level, which acted mainly as facilitators for NPs and barriers for RNs. These factors were: 1) policy and legislation; 2) organizational policy support (leadership and strategies to support nurses' practice change); facility and employment arrangements (supply and availability of human resources); Inter-professional collegiality; 3) professional boundaries; 4) knowledge and capabilities; and 5) patient perceptions. CONCLUSIONS: Our findings suggest that healthcare decision-makers and organizations need to redefine the boundaries of each category of nursing practice within AA, and create an optimal professional and organizational context that supports practice transformation. They highlight the need to structure teamwork efficiently, and integrate and maximize nurses' capacities within the team throughout AA implementation in order to reduce waiting times.

Evaluation of the implementation and associated effects of advanced access in university family medicine groups: a study protocol.

BACKGROUND: Timely access in primary health care is one of the key issues facing health systems. Among many interventions developed around the world, advanced access is the most highly recommended intervention designed specifically to improve timely access in primary care settings. Based on greater accessibility linked with patients' relational continuity and informational continuity with a primary care professional or team, this organizational model aims to ensure that patients obtain access to healthcare services at a time and date convenient for them when needed regardless of urgency of demand. Its implementation requires a major organizational change based on reorganizing the practices of all the administrative staff and health professionals. In recent years, advanced access has largely been implemented in primary care organizations. However, despite its wide dissemination, we observe considerable variation in the implementation of the five guiding principles of this model across organizations, as well as among professionals working within the same organization. The main objective of this study is to assess the variation in the implementation of the five guiding principles of advanced access in teaching primary healthcare clinics across Quebec and to better understand the influence of the contextual factors on this variation and on outcomes. METHODS: This study will be based on an explanatory sequential design that includes 1) a quantitative survey conducted in 47 teaching primary healthcare clinics, and 2) a multiple case study using mixed data, contrasted cases (n = 4), representing various implementation profiles and geographical contexts. For each case, semi-structured interviews and focus group will be conducted with professionals and patients. Impact analyses will also be conducted in the four selected clinics using data retrieved from the electronic medical records. DISCUSSION: This study is important in social and political context marked by accessibility issues to primary care services. This research is highly relevant in a context of massive media coverage on timely access to primary healthcare and a large-scale implementation of advanced access across Quebec. This study will likely generate useful lessons and support evidence-based practices to refine and adapt the advanced access model to ensure successful implementation in various clinical contexts facing different challenges.

Professional Role Identity: At the Heart of Medical Collaboration Across Organisational Boundaries.

PURPOSE: The purpose of this paper was to help answer two persistent calls in the literature: the first asks to strengthen the understanding of medical collaboration across levels of healthcare delivery; the second one requests paying more attention to the individual experience of different forms of professional work. Accordingly, the study was guided by the following research question: How do family physicians and specialists working at different levels of healthcare delivery enact their professional identity when interacting in their situated clinical contexts? METHODOLOGY: This was a multiple interpretive case study in which, based on Giddens' ideas, professional identity was viewed as a dynamic structural element of social life recursively related to professionals' collaborative actions through sensemaking processes. The study involved 57 participants. Face-to-face individual semi-structured interviews and organizational documents were the main sources of data. Deductive-inductive thematic analysis was adopted as strategy for data analysis. FINDINGS: Three prevailing physicians' identity roles were elicited: medical expert, care coordinator, and team member. These professional identities, not mutually exclusive, were instantiated in three specific modalities of collaboration: quasi-inexistent, restrained, and extended. The entanglement of a particular identity role and a specific collaborative practice became meaningful through a complex net of organizational and institutional features, and patients' nosological profiles.

The challenges of implementing advanced access for residents in family medicine in Quebec. Do promising strategies exist?

BACKGROUND: The advanced access (AA) model is a highly recommended innovation to improve timely access to primary healthcare. Despite that many studies have shown positive impacts for healthcare professionals, and for patients, implementing this model in clinics with a teaching mission for family medicine residents poses specific challenges. OBJECTIVE: To identify these challenges within these clinics, as well as potential strategies to address them. DESIGN: The authors adopted a qualitative multiple case study design, collected data in 2016 using semi-structured interviews (N = 40) with healthcare professionals and clerical staff in four family medicine units in Quebec, and performed a thematic analysis. They validated results through a discussion workshop, involving many family physicians and residents practicing in different regions Results: Five challenges emerged from the data: 1) choosing, organizing residents' patient; 2) managing and balancing residents' appointment schedules; 3) balancing timely access with relational continuity; 4) understanding the AA model; 5) establishing collaborative practices with other health professionals. Several promising strategies were suggested to address these challenges, including clearly defining residents' patient panels; adopting a team-based care approach; incorporating the model into academic curriculum and clinical training; proactive and ongoing education of health professionals, residents, and patients; involving residents in the change process and in adjustment strategies. CONCLUSIONS: To meet the challenges of implementing AA, decision-makers should consider exposing residents to AA during academic training and clinical internships, involving them in team work on arrival, engaging them as key actors in the implementation and in intra- and inter-professional collaborative models.

What Are the Factors Influencing Implementation of Advanced Access in Family Medicine Units? A Cross-Case Comparison of Four Early Adopters in Quebec.

INTRODUCTION: Advanced access is an organizational model that has shown promise in improving timely access to primary care. In Quebec, it has recently been introduced in several family medicine units (FMUs) with a teaching mission. The objectives of this paper are to analyze the principles of advanced access implemented in FMUs and to identify which factors influenced their implementation. METHODS: A multiple case study of four purposefully selected FMUs was conducted. Data included document analysis and 40 semistructured interviews with health professionals and staff. Cross-case comparison and thematic analysis were performed. RESULTS: Three out of four FMUs implemented the key principles of advanced access at various levels. One scheduling pattern was observed: 90% of open appointment slots over three- to four-week periods and 10% of prebooked appointments. Structural and organizational factors facilitated the implementation: training of staff to support change, collective leadership, and openness to change. Conversely, family physicians practicing in multiple clinical settings, lack of team resources, turnover of clerical staff, rotation of medical residents, and management capacity were reported as major barriers to implementing the model. CONCLUSION: Our results call for multilevel implementation strategies to improve the design of the advanced access model in academic teaching settings.

Perceptions of the first family physicians to adopt advanced access in the province of Quebec, Canada.

In Quebec, several primary care physicians have made the transition to the advanced access model to address the crisis of limited access to primary care. The objectives are to describe the implementation of the advanced access model, as perceived by the first family physicians; to analyze the factors influencing the implementation of its principles; and to document the physicians' perceptions of its effects on their practice, colleagues and patients. Qualitative methods were used to explore, through semi-structured interviews, the experiences of 21 family physicians who had made the transition to advanced access. Of the 21 physicians, 16 succeeded in adopting all five advanced access principles to varying degrees. Core implementation issues revolved around the dynamics of collaboration between physicians, nurses and other colleagues. Secretaries' functions, in particular, had to be expanded. Facilitating factors were mainly related to the physicians' leadership and the professional resources available in the organizations. Impediments related to resource availability and team functioning were also encountered. This is the first exploratory study to examine the factors influencing the adoption of the advanced access model conducted with early-adopter family physicians. The lessons drawn will inform discussions on scaling up to other settings experiencing the same problems. Copyright © 2016 John Wiley & Sons, Ltd.

The performance of primary health care organizations depends on interdependences with the local environment.

Purpose Improving the performance of health care organizations is now perceived as essential in order to better address the needs of the populations and respect their ability to pay for the services. There is no consensus on what is performance. It is increasingly considered as the optimal execution of four functions that every organization must achieve in order to survive and develop: reach goals; adapt to its environment; produce goods or services and maintain values; and a satisfying organizational climate. There is also no consensus on strategies to improve this performance. The paper aims to discuss these issues. Design/methodology/approach This paper intends to analyze the performance of primary health care organizations from the perspective of Kauffman's model. It mainly aims to understand the often contradictory, paradoxical and unexpected results that emerge from studies on this topic. Findings To do so, the first section briefly presents Kauffman's model and lays forward its principal components. The second section presents three studies on the performance of primary organizations and brings out the contradictory, paradoxical and unexpected results they obtained. The third section explains these results in the light of Kauffman's model. Originality/value Kauffman's model helps give meaning to the results of researches on performance of primary health care organizations that were qualified as paradoxical or unexpected. The performance of primary health care organizations then cannot be understood by only taking into account the characteristics of these organizations. The complexity of the environments in which they operate must simultaneously be taken into account. This paper brings original development of an integrated view of the performance of organizations, their own characteristics and those of the local environment in which they operated.

Mandated Local Health Networks across the province of Québec: a better collaboration with primary care working in the communities?

Background In 2004, the Québec government implemented an important reform of the healthcare system. The reform was based on the creation of new organisations called Health Services and Social Centres (HSSC), which were formed by merging several healthcare organisations. Upon their creation, each HSSC received the legal mandate to establish and lead a Local Health Network (LHN) with different partners within their territory. This mandate promotes a 'population-based approach' based to the responsibility for the population of a local territory. Objective The aim of this paper is to illustrate and discuss how primary healthcare organisations (PHC) are involved in mandated LHNs in Québec. For illustration, we describe four examples that facilitate a better understanding of these integrated relationships. Results The development of the LHNs and the different collaboration relationships are described through four examples: (1) improving PHC services within the LHN - an example of new PHC models; (2) improving access to specialists and diagnostic tests for family physicians working in the community - an example of centralised access to specialists services; (3) improving chronic-disease-related services for the population of the LHN - an example of a Diabetes Centre; and (4) improving access to family physicians for the population of the LHN - an example of the centralised waiting list for unattached patients. Conclusion From these examples, we can see that the implementation of large-scale reform involves incorporating actors at all levels in the system, and facilitates collaboration between healthcare organisations, family physicians and the community. These examples suggest that the reform provided room for multiple innovations. The planning and organisation of health services became more focused on the population of a local territory. The LHN allows a territorial vision of these planning and organisational processes to develop. LHN also seems a valuable lever when all the stakeholders are involved and when the different organisations serve the community by providing acute care and chronic care, while taking into account the social, medical and nursing fields.