Developing interdisciplinary maternity services ... - Wiley Online Library

Journal of Evaluation in Clinical Practice ISSN 1356-1294

Developing interdisciplinary maternity services policy in Canada. Evaluation of a consensus workshop jep_1326

238..245

Carmel M. Martin MBBS MSc PhD MRCGP FRACGP FAFPHM1 and Jan Kasperski RN MHSc CHE2 1

Associate Professor, Northern Ontario School of Medicine, Sudbury, ON, Canada Chief Executive Officer, Ontario College of Family Physicians, Toronto, ON, Canada

2

Keywords complex system, consensus, evaluation, health care policy, interprofessional, knowledge synthesis, maternity services, multidisciplinary Correspondence Dr Carmel M. Martin 81 the Waxworks Dublin 15 Ireland E-mail: [email protected] Accepted for publication: 27 August 2009 doi:10.1111/j.1365-2753.2009.01326.x

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Abstract Context Four maternity/obstetrical care organizations, representing women, midwives, obstetricians and family doctors conducted interdisciplinary policy research under auspices of four key stakeholder groups. These projects teams and key stakeholders subsequently collaborated to develop consensus on strategies for improved maternity services in Ontario. Objectives The objective of this study is to evaluate a 2-day research synthesis and consensus building conference to answer policy questions in relation to new models of interdisciplinary maternity care organizations in different settings in Ontario. Methods The evaluation consisted of a scan of individual project activities and findings as were presented to an invited audience of key stakeholders at the consensus conference. This involved: participant observation with key informant consultation; a survey of attendees; pattern processing and sense making of project materials, consensus statements derived at the conference in the light of participant observation and survey material as pertaining to a complex system. The development of a systems framework for maternity care policy in Ontario was based on secondary analysis of the material. Findings Conference participants were united on the importance of investment in maternity care for Ontario and the impending workforce crisis if adaptation of the workforce did not take place. The conference participants proposed reforming the current system that was seen as too rigid and inflexible in relation to the constraints of legislation, provider scope of practice and remuneration issues. However, not one model of interdisciplinary maternity/obstetrical care was endorsed. Consistency and coherence of models (rather than central standardization) through self-organization based on local needs was strongly endorsed. An understanding of primary maternity care models as subsystems of networked providers in complex health organizations and a wider social system emerged. The patterns identified were incorporated into a complexity framework to assist sense making to inform policy. Discussion Coherence around core values, holism and synthesis with responsiveness to local needs and key stakeholders were themes that emerged consistent with complex adaptive systems principles. Respecting historical provider relationships and local history provided a background for change recognizing that systems evolve in part from where they have been. The building of functioning relationships was central through education and improved communication with ongoing feedback loops (positive and negative). Information systems and a flexible improved central and local organization of maternity services was endorsed. Education and improved communication through ongoing feedback loops (positive and negative) were central to building functioning relationships. Also, coordinated central organization with a flexible and adaptive local organization of maternity services was endorsed by participants. Conclusions This evaluation used an approach comprising scoping, pattern processing and sense making. While the projects produced considerable typical research evidence, the key policy questions could not be addressed by this alone, and a process of synthesis and consensus building with stakeholder engagement was applied. An adaptive system with local needs driving a relationship based network of interdisciplinary groupings or teams with both bottom up and central leadership. A complexity framework enhanced sense making for the system approaches and understandings that emerged.

© 2010 The Authors. Journal compilation © 2010 Blackwell Publishing Ltd, Journal of Evaluation in Clinical Practice 16 (2010) 238–245

C.M. Martin and J. Kasperski

Introduction Four leading maternity care organizations that research, educate and support the providers of obstetrical1 care in Ontario, in conjunction with the Ontario Ministry of Health and Long-Term Care (MOHLTC) Maternity Services Strategy, participated in policy research activities funded by the Pan Canadian Primary Health Care Transition Fund (PHCTF) 2003–2006 [1]. Their goal was to develop collaborative responses to key policy questions, to test the assumption that there is an impending workforce crisis, and to develop consensus on strategies for improved maternity services in Ontario. The activities took place in four research projects worth collectively more than five million Canadian dollars conducted under auspices of four key stakeholder groups – women, midwives, obstetricians and family doctors: 1 Ontario Maternity-Care Expert Panel – a women’s oriented multidisciplinary group. 2 Ryerson University/Integrated Maternity Care for Rural and Remote Communities – lead by community midwives. 3 Multidisciplinary Collaborative Primary Maternity Care Project [2] auspiced through the College of Obstetrics and Gynaecologists. 4 Babies Can’t Wait Project conducted by the College of Family Physicians, Canada. The four projects conducted primary research on models of maternity care, based on an analysis of Canadian health statistics, survey work and analysis of stakeholder narratives obtained through qualitative methods. The initial aims were to gain consensus on models of care that will stabilize and enhance primary care obstetrics in Ontario (and the whole of Canada) through interdisciplinary teams of obstetrical providers. The aims were subsequently modified in that the focus shifted to understanding the models of maternity/obstetrical care that would retain current practitioners and recruit new practitioners to maternity services, particularly with respect to intrapartum care. In addition, in relation to these four maternity care projects, a consensus conference – Ideas into Action, Consensus Conference 2006 [3] – was conducted to synthesize key themes and provide recommendations. It aimed to build consensus around interdisciplinary collaborative maternity services and obstetrical service delivery among the key stakeholders, consistent with the community development project for rural/ remote communities.

Background A review of doctor and midwifery human resource databases in Canada reveals that a high percentage of obstetricians are near retirement, that family doctors are withdrawing from intrapartum care, and that there are too few midwives to address the projected gaps in service provision [4]. Nursing maternity care education has not kept pace with the full potential of nursing roles in the labour room [5]. While the MOHLTC has been increasing medical undergraduate education and Family Medicine training places, there is no guarantee that new practitioners will choose the specialty of 1

Maternity care is the term preferred by some provider groupings, maternity care became the broader all encompassing title to reflect prenatal to post natal and neonatal care. The term obstetrics was retained by some groups for intrapartum care.

© 2010 The Authors. Journal compilation © 2010 Blackwell Publishing Ltd

Maternity services policy in Canada

Obstetrics or practice intrapartum care in Family Medicine. Given MOHLTC predictions of rising birth rates, there is a broadly based assumption among provider groups and organizations that there is a looming crisis in maternity services workforce province-wide and existing crises in some locations. This paper presents a case study evaluation of the Consensus Conference process based on complexity principles to address selected key MOHLTC and stakeholder policy questions across all four projects. Complexity theory supports the notion of organizations as dynamic, living, social systems [6]. Research observations that target patterns of relationships, interactions and processes over time are key to understanding a complex system [6]. A search for patterns implies attention to the flow of behaviour within systems rather than merely describing static behaviour [7]. Consensus was identified as the most appropriate method to synthesize research findings in this context [8].

Aims This evaluation case study examined how the activities of four projects through the Consensus Conference addressed the key questions using a complexity framework: 1 What are the key messages and patterns across all the projects in response to two key questions? • How should the mix and number of providers on a multidisciplinary team reflect needs of community or practice population? • What factors facilitate health care providers working together to provide comprehensive PHC (scope of practice, funding, education)? 2 How to make sense of the findings using a complex systems perspective

Methods of the evaluation The following methods were used (Fig. 1): 1 A scoping of individual project activities and findings as were presented to an invited audience of key stakeholders, and the consensus process for policy recommendations was conducted [9]. 2 Participant observation with key informant consultation of working groups and a survey of conference participants. 3 Analysis key themes and patterns in project materials, consensus statement, observation and survey material. 4 Sense making [10] of project materials, consensus statement derived at the conference in the light of participant observation and survey material as pertaining to a complex system. 5 Development of a systems framework for maternity care policy in Ontario based on secondary analysis of the material.

Findings In 25–26 May 2006, 180 key stakeholders attended the ‘Ideas into Action: Maternity Care Solutions for Ontario – A Consensus Building Workshop’ and presented key findings. The participants were from the following organizations: Ryerson University Department of Midwifery, University of Toronto, Department of Community and Family Medicine; The University of Western Ontario, Department of Family Medicine; McMaster University, Department of Family Medicine; The Ontario Medical Associa239


Development of a complexity framework for maternity care policy in Ontario

Research results

Sense making & synthesis


Conference Materials & Presentation of projects key findings: testing interdisciplinary models; surveys of women, providers, managers, learners &literature/data analysis

Consensus

Participant observation Key informant consultation Survey of participants .

Identification of key themes and key narratives using a complex systems framework

Thematic and pattern analysis

Figure 1 Methods of Evaluation of Maternity Care Services Consensus Conference.

tion; The Association of Ontario Midwives; The Ontario Hospital Association; The Society of Obstetricians and Gynecologists; The Society of Rural Physicians; Ontario Maternity Care Expert Panel; Canadian Nurses Association, National Aboriginal Health Organization, Ontario Community Health Centre Association [11].

Changing trends in Obstetrical Physician Human Resources, Ontario 1992–2005 An analysis of existing data sources – MOHLTC Provider Databases for Physician Services, OPHRDC 2004 and MOHLTC Ontario Midwifery Program identified major human resource trends. The total number of doctor attended births has decreased. There has been a near linear decrease in family practice births, obstetricians are delivering over 80% of the babies in the province and are the backbone of the primary, secondary and tertiary maternity care system. Obstetrician attended births are stable. There was a slow steady rise over time of midwifery births. However 14% of midwifery attended births also required obstetrician care as well as midwifery, and thus there is overlap among the groups. The most productive doctors are middle aged. In the next 10–15 years, with a Ministry predicted rise in births, older high volume doctors will slow down or retire. Younger, low volume doctors will be the largest group. Family practice will decline and midwifery will gradually deliver a significantly greater proportion of normal births. There is an impending crisis in maternity services if the birth rate increases significantly and the younger obstetricians do not expand their volumes, family practice continues to decline and midwifery cannot expand sufficiently to address the demand.

Models of collaborative maternity practice In 1999–2000, 34.6% of women giving birth in Ontario hospitals had a spontaneous labour and unassisted vaginal birth. This rate has decreased steadily. In 2003–2004, the rate had decreased to 31.5%. 240

There were wide regional variations. Spontaneous labour and unassisted delivery rates varied from 47.8% to 24.2%. The percentage of women, who received maternity care services in hospitals in 2003/ 2004 by different maternity care professionals for the whole of Ontario is: obstetricians – 81.9%, family physicians – 14%, and midwives – 3.3%. However, in the most remote areas the percentage of women who received services from obstetricians was 47%, family physicians 40%, and midwives 11.5% [18].

Midwife, obstetrician and family doctor models of collaborative care The following models were identified and endorsed across the projects [12]. Uniprofessional • Uniprofessional (soft-call) – on-call most of time, attend birth unless signed out • Uniprofessional (hard-call) – have set on-call time (i.e. day, week or month) • Shared on-call – call shared between family doctor and midwives with obstetrician back-up • Late prenatal and intrapartum care – receive referral for late prenatal and intrapartum • Care • Labourist – Provide intrapartum care only Multiprofessional • Multiprofessional team – work in clinic with other maternity care providers and allied health, and consult when necessary Interprofessional • Work in clinic with other maternity care providers and allied health professionals, and have regular team meetings.

Specific findings from the projects Table 1 presents the background, methods and key findings of each project in detail. Each project expressed similar concerns about quality and sustainability of maternity care in Ontario with current models and identified the need for new models based on collaboration. Consistently, there was no endorsement of any particular model, rather an endorsement to reform system constraints to allow flexibility which are described the consensus statement.

The consensus statement Consensus processes to identify key themes and patterns in the research findings were conducted by the workshop organizers with participants in small groups answering key questions using majority agreement. This resulted in a draft consensus statement from the workshop for representatives to take back to their constituencies. Table 1 describes the key themes that emerged from the consensus process (Table 2).

Evaluation fieldwork Participant observation, key informant interviews and surveys of participants to identify key were conducted [13]. Stakeholders assessed the consensus process and findings based on anonymous exit survey. On days one and two, 120 surveys were distributed to conference participants, and 85 (70%) of them completed.


Representative panel of professionals, one consumer and PHCTF project team members, was created by Ontario Women’s Health Council in Oct 2004 Aimed to identify the status of maternity care across Ontario regions

Survey of 109 hospitals in Ontario, including both current or recently ceased providers of maternity care; Literature reviews and environmental scans in the following areas: Women’s Input into Maternity Care; Human Resources Planning; Models of Maternity Care; Legislation/Regulation; Remuneration and Funding Schemes; Liability Insurance; Data and Evaluation Systems; User focus groups web-based survey; Stakeholder Consultation

Increased Rates of Induction and Instrumental Methods of Delivery are of concern Collaboration across the maternity care continuum is essential with broader role for non-medical providers.

Project identified innovative models of maternity care addressing workforce, remuneration and regulation issues need implementation, yet did not recommend any particular model.

Methods

Key issues/ findings

Proposed solutions

Ontario Maternity Care Expert Panel (OMCEP)

Background

Project

Babies Can’t Wait The Ontario College of Family Physicians auspiced this multidisciplinary project. Aims were to gain consensus on models of care that will stabilize and enhance primary care obstetrics in Ontario through interdisciplinary teams. Subsequently shifted to understanding the models of maternity/obstetrical care that would retain current practitioners and recruit new practitioners to maternity services, particularly intrapartum care. Literature Review and Data Analysis: Investigating Workforce, Services and Quality Patterns in Order to Develop Maternity Care Models Field Work – Understanding Models of Collaborative Maternity Care Surveys, interviews and focus groups were conducted with providers (current and future) Organization (hospitals and universities/ colleges) surveys, interviews and focus groups were conducted with representatives from organizations (hospitals and universities/colleges).

The analysis identified current human resources and future projections. No one model fits everyone’s needs, but most professionals want a collaborative model. Interprofessional activities must encompass education, collaboration, sustainability, funding and implementation. Collaboration must start in education. A series of proposed model(s) of maternity care were identified that would fit with both urban needs and the realities of rural/remote communities and their preferences.

Multidisciplinary Collaborative Primary Maternity Care (MCP2) Association of Women’s Health, Obstetric and Neonatal Nurses Canada; Canadian Association of Midwives, College of Family Physicians of Canada, Society of Obstetricians and Gynaecologists of Canada, and Society of Rural Physicians of Canada. and Canadian Nurses Association Aimed to address the human resources shortage crisis in Canadian intrapartum care across all maternity care providers. Analysis of the maternity care system and collaborative models of care in the UK, the Netherlands, Germany, France, Sweden and Australia Review of provincial and territorial legislation regulating family doctors, nurses, nurse practitioners and midwives and a comparative analysis of legislation; Establish National Primary Maternity Care Committee of associations, provincial governments and consumers. Knowledge translation to facilitate change in practice for maternity care providers; and promote multidisciplinary collaborative primary maternity care. A crisis shortage of maternity care providers in Canada – family doctors, obstetricians, nurses and midwives Can be addressed by the implementation of multidisciplinary collaborative maternity care models with 24-hour/ 365-day coverage for low-risk intrapartum care. Addresing regulatory issues, limitations and inflexibility in Scope of Practice, financial, economic issues, medico-legal and liability issues, and with health care providers collaborative education

Integrated Maternity Care for Rural & Remote Communities (IMCRRC) Ryerson University’s Midwifery Education Program. project Aimed to develop new models of maternity care integrate midwives into collaborative models with nurses and doctors

Identification of 6 rural and remote communities in Ontario with shortages of nurses and doctors, falling birth numbers, geographic isolation, or temporary closure of hospital maternity units Local working groups were formed of nurses, midwives, family doctors, nurse practitioners, public health nurses, community and programme managers. Researchers conducted Interviews of care providers; Focus groups of consumers; Participatory action work (4) Teleconference focus groups, of representatives from the 6 communities A Rural Crisis is impending within 10 years. Local solutions, should guide the transformation process in community maternity care services. Rural communities have unique needs/ solutions to different challenges. Keeping women in the community with local care

Good communication in flexible work environments with local innovation and collaboration promote obstetricians, family doctors, midwives, registered nurses, etc., collaboratively improving quality.

Table 1 Summary of four projects on maternity care services as presented to the Ideas into Action Conference Workshop, Toronto Ontario 2006

C.M. Martin and J. Kasperski Maternity services policy in Canada


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Table 2 Key Points in a Draft Consensus Statement from the Ideas into Action Workshop 2006 (Three Ontario specific recommendations about specific provider groups and local organizations are not included) 1 There is a need to recognize that maternal/child care is vitally important to the ongoing well-being of Ontarians and key to long-term economic prosperity. Investing in healthy moms and babies is an investment in the health of future generations of Ontario citizens and therefore Ontario – in general. 2 The current system is uncoordinated and unsustainable with looming human resources shortages. No one model of care will result in the recruitment and retention of maternity care providers. Multiple models and flexibility is needed as key to address health human resources issues in maternity care. 3 Leadership is needed, at the provincial level, to create and sustain a new vision of maternity care. 4 All involved institutions, maternity care professionals and consumers should play key roles in developing a culture of quality, cooperation and collaboration at each hospital and in each region that recognizes and supports all providers as key to the retention of current maternity care professionals and the recruitment of new professionals to their ranks. 5 The educational environment needs to change dramatically to provide nurses, midwives, Family Medicine and Obstetrics residents with opportunities to learn together (and from one another) in maternity care units that demonstrate interdisciplinary collaborative practices, cooperation between professionals, and the joy (rather than fear) of childbirth. 6 Research, evaluation and data collection should be used to develop and showcase models of care that work and in the development of policies, procedures, standing orders, etc.; however, consistency, rather than standardization, should be the aim. 7 Local solutions that are developed and implemented by all stakeholders, including consumers, are needed to address local needs and to maximize local resources. 8 Cross-training between midwives, nurses and nurse practitioners needs to be supported. 9 Regulatory, legislative, liability and malpractice issues need to be addressed to better support primary maternity care and facilitater integrated, collaborative models of care. 10 Providers’ education needs to be enhanced through easy access 11 Funding and compensation issues need to be addressed. Barriers to collaboration in the funding models need to be removed and competitive rates of remuneration are needed. 12 Public education regarding childbirth as a normal life event, as well as the need for changes in the models of care, was also recommended.

Participants assessed of the project finding as good to excellent in terms of relevance (92.6–98.7%), importance (87.3–98.7%) and quality (82.1–97.3%). How should the mix and number of providers on a multidisciplinary team reflect needs of community or practice population? The 85 survey respondents identified key themes in an openended question from all the projects in the following frequency: • Action needed as workforce crisis is now and long-term (49); • Local needs should drive maternity care organization (40); • Collaboration essential (40); • Flexible models or flexibility a priority (20); • Interprofessional education is very important (12); • Close-to-home maternity care a priority (6); • Importance of MOHLTC role, strategy and funding – for example branch, coordinating committee or other options (4). Collaboration among providers were identified as central to the policy question of ‘What factors facilitate maternity care providers working together to provide comprehensive maternity care, which is an integral part of PHC (e.g. scope of practice, funding, and education)?’ The stakeholder narratives from the Consensus Conference commonly assert that ‘barriers to collaboration in the funding models need to be removed and competitive rates of remuneration are needed . . . Funding and compensation issues need to be addressed’ (Consensus Statement Conference, 2006). Moreover, ‘an appropriate recognition, regulation and remuneration of midwives and nurse practitioners as providers of maternal/ newborn care services in all jurisdictions throughout Canada is a requirement for new models’ (MCP2 recommendations). Stakeholder narratives also suggest that ‘the development of shared-care models that recognizes and better coordinates prenatal, intrapartum and post-partum care between the disciplines is needed’ 242

(Consensus Conference Statement, 2006). All the foregoing shed some light on the MOHLTC and stakeholder policy questions. More importantly, while the consensus conference participants were very satisfied with the process, a number of issues which are central to the MOHLTC policy questions were identified as being unanswered [13]. The conference participants proposed reforming the current system that was too rigid and inflexible in relation to the constraints of legislation, provider scope of practice and remuneration issues. Also, they felt that in some areas the system was too chaotic with breakdown of services, hospital closures and turf warfare. The ideal for them was neither rigid and standardized nor uncoordinated and with huge variations in practice and quality. The preferred system was coherent and consistent, being flexible within constraints that allowed freedom to self-organize at a local level and within multidisciplinary care models. The opportunity that the PHCT funding provided was to test different models and ways of interprofessional collaboration. This encouraged participants to take considered risks. Mistakes that arose from these were best seen as an opportunity for reflection and professional/ organizational learning. Autonomy and responsibility were more important and locally adaptive than imposed standardization of care to women, communities and the providers. This meant working in an atmosphere of considerable personal freedom, but with that came the cost of making that freedom productive for women, their families and the health system overall. The emergence of many complicated issues in the consensus process demonstrates the multiple facets of the policy questions. A minority (5–30%) of respondents were found to need more attention. From the participants’ perspective, women and their families were seen as central to improving service delivery. However, these concerns were not sufficiently addressed and



too much emphasis was placed on professionals. Workforce issues were central to the crisis, but greater attention to recruitment, health human resources issues and student encouragement was needed. Also, the hard issues of different philosophies of care, power, economics, turf wars and local resistance to change were insufficiently addressed.

Patterns Coherence around core values The consensus statement identified core values for Ontario Maternity Care Services reflected in the following quotes: Maternal/child care is vitally important to the ongoing wellbeing of Ontarians and key to long-term economic prosperity. Investing in healthy moms and babies is an investment in the future. Woman or women’s rights/needs of family, partner, consumer are central. The delivery of maternity care is a complex process.


History contains meaning of change and systems evolve in part from where they have been Participants felt that the hard issues of philosophies of care, power, economics, turf wars, local resistance to change need to be accounted for and addressed. There is a need to identify what the ‘real’ birthing related functions are – both explicit and tacit from women.

Functioning of relationships and feedback loops (positive and negative) Creating new variety and ever new manifestations of order against a background of constant change was recognized as an important systems perspective [2]. When restructuring the workforce, form should follow function in reform rather than vice versa; both should follow values. Feedback loops with the space for possibilities to adjust the status quo allows for self-organization.

Sense making A complex system – understandable but non-predictable, can contain known and knowable subsystems Broadly based problems like overextended facilities, shortage of maternity care practitioners, the current epidemic of cesarean sections or the specter of medicolegal liability [14] were central to the concerns of the projects and the consensus conference. While there was no debate about the relevance of some best practices in clinical care in services maternity [15], how this would be delivered and adapted to local circumstances was based on the evolution of knowledge connected to local community needs over time. This reflects that the system is complex with emergence, unpredictable with subsystems of stable best practice. Participants recognized the need to recognize the rationality yet unpredictability of model implementation. The consensus statement stated: ‘No one model of care will result in the recruitment and retention of maternity care providers. Multiple models and flexibility is needed as key to address health human resources issues in maternity care’ were statements supported by conference participants. And more pointedly, as stated by a participant ‘The current system is uncoordinated and unsustainable with looming human resources shortages’.

Leadership and policy synthesis require holistic synthesis and responsiveness to multiple audiences of key stakeholders in central and local jurisdictions Leadership is needed, at the provincial level, to create and sustain a new vision of maternity care. ‘One size does not fit all’ was often quoted by participants verbally and in the survey. Care providers as were identified as ‘care networks – interconnected, interdependent’ and operating in a social ecology. Maternity care women and baby and family-centred systems can be understood as complex adaptive networks. Local system needs and strengths should become a major influence on policy and practice [14].


The challenge is: how to project the needs for a changing maternity workforce, given the emerging project findings of local solutions – one-size does not fit all – and the lack of consensus about any ideal models? Even a multiplicity of potential new models and the numerous existing models might not reflect the needed variations at local levels. How can evidence be made useful to inform local planning in identifying the needs of local communities?

Complexity framework Complexity emerges from the patterns of interaction among the agents. Interactions are non-linear, meaning that small ‘causes’ may have large effects and large ‘causes’ may have small effects [7]. The overarching explicit theory identified at the consensus conference was complex systems, interpreted to mean multiple solutions and approaches at different level [14]. A complex adaptive dynamic framework is described in comparison with a linear hierarchical static and rigid framework (Table 3). A systems and complexity approach was explicit in the setting up of the projects [2]. The evaluation identified patterns that are consistent with this complexity framework. It is argued this framework assists in making sense of the multiple findings from four diverse projects from different stakeholders and a consensus process. Core values allow the ordering of particulars, facts or events into general ideas and form emotional associations with them and they also shape our commitments to them.[5] Multiple possible research and evaluation perspectives can inform questions about the mix and match of key providers on a multidisciplinary care team [16], and yet synthesis requires participation by agents and stakeholders. Narrow analyses may actually impede ‘improvement’ by making rigid structures which are not adaptable [17].

Primary Maternity Care – a complex adaptive system Initially, the projects and the Ministry of Health and Long Term Care sought to identify best practice models of multidisciplinary 243



Table 3 A complexity framework (adapted from Martin and Sturmberg, 2005 and based on Snowden, Glouberman, Middleton-Kelly) Simple or Complicated Systems Framework (Assumptions of linearity and stability)

Complex Adaptive Systems Framework (Assumptions of dynamic interdependency and changing)

‘Value free and scientific’ Driven by Known Facts and Evidence-based condition knowledge and processes

Coherence around core values [6] Value based decisions informed by derived data, stakeholder narratives and ongoing system feedback Values co-exist in networks of agents, not as individual entities. Even once a value is identified, what does it mean when professed by different agents. [2] People, human processes such as intrapartum care; administrative processes, and political systems are examples of agents. [3]

Known and knowable Legitimate best model, provider, practice, and predictable One model of multidisciplinary maternity services can and should be identified

Understandable but non-predictable, can contain known and knowable subsystems [7] Respect for emergent and evolved knowledge as well as traditional linear evidence Self-organization results in the most adaptive local solution Emergence Agents interacting in a non-linear way may self can cause unpredictable system properties to emerge.

Reductionism/analysis and standardization/central accountability All models of multidisciplinary maternity services should have the following features with a check list

Holism/synthesis/responsiveness to local needs and key stakeholders [8] Need to understand the whole context to understand the contained meaning Self-organization is the process by which agentsmutually adapt behaviours to cope with changing internal and external environmental demands Thus they create the new structures and behaviours needed to meet changet [4,5].

Classical economics ignores historical evidence as systems always tend to equilibrium Reform means rejecting the views, sensitivities, and ways of the past and creating more cost effective new approaches, even though the system will have innate resistance and inertia

History contains meaning of change and systems evolve in part based on where they have been Building change on the current history and dynamics of the system, shifting the point of equilibrium

Measures of efficiency, process and best practice Selective features which are easily measured are accorded best practice status and drive the system

Functioning of relationships and feedback loops (positive and negative) shape system patterns Complicated ambiguous health knowledge co-constructed through stakeholder narrative and ongoing adaptation and feedback. Interconnections are local, patterns are global [5]

Other features of complex systems include: Co-Evolution Complex adaptive systems are open, and thus agents interact with others in the environment extending the interactions and information exchanges beyond the system boundaries Because of co-evolution, the system’s current and future behaviour is intricately linked to its history [19].

intrapartum care for low-risk pregnant women in Ontario. The questions asked looked for the optimum mix of providers in terms of meeting needs and efficiency, and how could those providers be facilitated in working together. What emerged, however, was essentially a strategy for primary maternity care tacitly based on complex adaptive system understandings, with recommendations for flexibility and interconnections based on relationships between women and providers. The findings from this evaluation develop an emergent understanding of Primary Maternity Care Models as subsystems of networked providers in complex health organizations and a wider social system. Core Values and the impending workforce crisis if adaptation of the workforce did not take place united the broad range of providers around the importance of maternity care. The future of maternity care policy in Ontario as consistency and coherence (rather standardization), ‘The ability to adapt to changing environments,’ was a consistent theme. Both the traditional 244

organizational structures (and theory) and clinical practice can be transformed to shift to produce new functions with insights from complexity. However, it requires a major reverse of current top down policy making and professional silos. The ‘edge of chaos’, when there is flux and uncertainty in a system rather than allowing adaptation with new patterns to emerge, hierarchical approaches tend to increase rigidity and central control. The conference participants proposed reforming the current system that was too rigid and inflexible in relation to the constraints of legislation, provider scope of practice and remuneration issues. Also, they felt that in some areas it was too chaotic with breakdown of services, hospital closures and turf warfare. The ideal for them appeared to be a system functioning between chaos and rigidity, being flexible within constraints that allowed freedom to self-organize at a local level and within multidisciplinary care models. The opportunity that the PHCT funding provided was to test different models and ways of interprofessional collaboration.



This encouraged participants to take considered risks. Mistakes that arose from these were best seen as an opportunity for reflection and professional/organizational learning. Autonomy and responsibility were more important and locally adaptive than imposed standardization of care to women, communities and providers. This meant working in an atmosphere of considerable personal freedom, but that with that came the cost of making that freedom productive for women, their families and the health system overall.

Conclusion This evaluation used an approach comprising scoping, pattern processing and sense making. Four major research projects presented and analysed their findings collaboratively at a Consensus Conference. While the projects produced considerable typical research evidence, the key policy questions could not be addressed by this alone, and a process of synthesis and consensus building with stakeholder engagement was applied. The original objective was to identify a model or a few models of multidisciplinary care that would allow workforce planning. However, an adaptive system with local needs driving a relationship based network of interdisciplinary groupings or teams with bottom up and central leadership was identified. A complexity framework provided coherence for the system approaches and understandings about education and workforce policy that emerged. Ultimately, the decision about the mix of providers will be informed by the research, contextualized by the provincial political economy. The findings of the synthesis and consensus building process endorsed common values across the diverse, and sometimes competing and conflicting groups of providers, were a basis of addressing questions about the mix and make up of multidisciplinary maternity teams in preferred models of care. This evaluation identified that while the projects produced considerable linear and traditional evidence, the key policy questions could not be addressed by this alone, and a process of consensus with stakeholder engagement was applied. A complexity framework provided a mechanism for sense making for policy.

References 1. Health Canada (2007) Primary Health Care Transition Fund, Funded Initiatives. Ottawa. Available at: http://www.apps.hc-sc.gc.ca/hcs-sss/ prim/phctf-fassp/pchtf.nsf/WEB_E?OpenForm (last accessed 9 December 2009). 2. Society of Obstetricians and Gynaecologists of Canada, Association of Women’s Health, Obstetric and Neonatal Nurses, Canadian Association of Midwives, Canadian Nurses Association, College of Family Physicians of Canada & Canada, S. o. R. P. o. (2006) Multidisciplinary Collaborative Primary Maternity Care National Envelope – National Strategy on Collaborative Care; Primary Health Care Transition Fund. Available at: http://www.mpc2.ca (last accessed 9 December 2009). 3. Kasperski, J. (2006) Actively Building Capacity in Interdisciplinary



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