Tinkering at the margins: evaluating the pace and direction of primary care reform in Ontario, Canada

A shifting terrain: Understanding the perspectives of walk-in physicians on their roles amid worsening primary care access in Ontario, Canada

BACKGROUND

High-quality primary care is associated with better health outcomes and more efficient and equitable health system performance. However, the rate of primary care attachment is falling, and timely access to primary care is worsening, driving many patients to use walk-in clinics for their comprehensive primary care needs. This study sought to explore the experiences and perceived roles and responsibilities of walk-in physicians in this current climate. Methods: Qualitative interviews were conducted with nineteen physicians currently providing walk-in care in Ontario, Canada between May and December 2022.

RESULTS

Limited capacity for continuity and comprehensiveness of care were identified as major sources of professional tension for walk-in physicians. Divergent perspectives on their roles were anchored in how physicians viewed their professional identity. Some saw providing continuous and comprehensive care as an infringement on their professional role; others saw their professional role as more flexible and responsive to population needs. Regardless of their professional identity, participants reported feeling ill-equipped to manage the swell of unattached patients, citing a lack of time, resources, connectivity to the system, and remuneration flexibility. Conclusions: As practice demands of walk-in clinics change, an evolution in the professional roles and responsibilities of walk-in physicians follows. However, the resources, structure, and incentives of walk-in care have not evolved to reflect this, leaving physicians to set their own professional boundaries with patients. This results in increasing variations in care and confusion across the primary care sector around who is responsible for what, when, and how.

Reforms and innovations in primary health care in different countries: scoping review

INTRODUCTION

The World Health Organization (WHO) recommends focusing on primary health care (PHC) as the first strategy of countries to achieve the improvement of the health level of communities and has emphasized it again in 2021. Therefore, we intend to take a different look at the PHC system with reform, innovation, and initiative by using the experiences of leading countries and identify practical and evidence-based solutions to achieve greater health.

METHODS

This is a scoping review study that has identified innovations and reforms related to PHC since the beginning of 2000 to the end of 2022. In this study, Scopus, Web Of Science, and PubMed databases have been searched using appropriate keywords. This study is done in six steps using Arkesy and O'Malley framework. In this study, the framework of six building blocks of WHO was used to summarize and report the findings.

RESULTS

By searching in different databases, we identified 39426 studies related to reforms in primary care, and after the screening process, 106 studies were analyzed. Our findings were classified and reported into 9 categories (aims, stewardship/leadership, financing & payment, service delivery, health workforce, information, outcomes, policies/considerations, and limitations).

CONCLUSION

The necessity and importance of strengthening PHC is obvious to everyone due to its great consequences, which requires a lot of will, effort, and coordination at the macro-level of the country, various organizations, and health teams, as well as the participation of people and society.

Adapting care provision in family practice during the COVID-19 pandemic: a qualitative study exploring the impact of primary care reforms in four Canadian regions

BACKGROUND

Over the past two decades, Canadian provinces and territories have introduced a series of primary care reforms in an attempt to improve access to and quality of primary care services, resulting in diverse organizational structures and practice models. We examine the impact of these reforms on family physicians' (FPs) ability to adapt their roles during the COVID-19 pandemic, including the provision of routine primary care.

METHODS

As part of a larger case study, we conducted semi-structured qualitative interviews with FPs in four Canadian regions: British Columbia, Newfoundland and Labrador, Nova Scotia, and Ontario. During the interviews, participants were asked about their personal and practice characteristics, the pandemic-related roles they performed over different stages of the pandemic, the facilitators and barriers they experienced in performing these roles, and potential roles FPs could have filled. Interviews were transcribed and a thematic analysis approach was applied to identify recurring themes in the data.

RESULTS

Sixty-eight FPs completed an interview across the four regions. Participants described five areas of primary care reform that impacted their ability to operate and provide care during the pandemic: funding models, electronic medical records (EMRs), integration with regional entities, interdisciplinary teams, and practice size. FPs in alternate funding models experienced fewer financial constraints than those in fee-for-service practices. EMR access enhanced FPs' ability to deliver virtual care, integration with regional entities improved access to personal protective equipment and technological support, and team-based models facilitated the implementation of infection prevention and control protocols. Lastly, larger group practices had capacity to ensure adequate staffing and cover additional costs, allowing FPs more time to devote to patient care.

CONCLUSIONS

Recent primary care system reforms implemented in Canada enhanced FPs' ability to adapt to the uncertain and evolving environment of providing primary care during the pandemic. Our study highlights the importance of ongoing primary care reforms to enhance pandemic preparedness and advocates for further expansion of these reforms.

Building High-Performing Primary Care Systems: After a Decade of Policy Change, Is Canada "Walking the Talk?"

Policy Points Considerable investments have been made to build high-performing primary care systems in Canada. However, little is known about the extent to which change has occurred over the last decade with implementing programs and policies across all 13 provincial and territorial jurisdictions. There is significant variation in the degree of implementation of structural features of high-performing primary care systems across Canada. This study provides evidence on the state of primary care reform in Canada and offers insights into the opportunities based on changes that governments elsewhere have made to advance primary care transformation.

CONTEXT

Despite significant investments to transform primary care, Canada lags behind its peers in providing timely access to regular doctors or places of care, timely access to care, developing interprofessional teams, and communication across health care settings. This study examines changes over the last decade (2012 to 2021) in policies across 13 provincial and territorial jurisdictions that address the structural features of high-performing primary care systems.

METHODS

A multiple comparative case study approach was used to explore changes in primary care delivery across 13 Canadian jurisdictions. Each case consisted of (1) qualitative interviews with academics, provincial health care leaders, and health care professionals and (2) a literature review of policies and innovations. Data for each case were thematically analyzed within and across cases, using 12 structural features of high-performing primary care systems to describe each case and assess changes over time.

FINDINGS

The most significant changes include adopting electronic medical records, investments in quality improvement training and support, and developing interprofessional teams. Progress was more limited in implementing primary care governance mechanisms, system coordination, patient enrollment, and payment models. The rate of change was slowest for patient engagement, leadership development, performance measurement, research capacity, and systematic evaluation of innovation.

CONCLUSIONS

Progress toward building high-performing primary care systems in Canada has been slow and variable, with limited change in the organization and delivery of primary care. Canada's experience can inform innovation internationally by demonstrating how preexisting policy legacies constrain the possibilities for widespread primary care reform, with progress less pronounced in the attributes that impact physician autonomy. To accelerate primary care transformation in Canada and abroad, a national strategy and performance measurement framework is needed based on meaningful engagement of patients and other stakeholders. This must be accompanied by targeted funding investments and building strong data infrastructure for performance measurement to support rigorous research.

Training in Team-Based Practices: A Descriptive Analysis of Family Medicine Postgraduate Site Distribution across Canada

Background

College of Family Physicians of Canada accreditation policies contemplate exemplary ratings for postgraduate family medicine programs that train residents in sites aligned with the Patient's Medical Home (PMH) vision. This may overrepresent the PMH in training relative to what is available in independent practice.

Methods

We appraised training sites to describe the degree to which PMH features are present in family medicine education across the country.

Results

More than half (70.7%) of Canadian training sites reflect PMH features.

Conclusion

Education policy that incentivizes PMH in training may create downstream tension for physicians who find these practices unavailable upon graduation.

The association between patients' timely access to their usual primary care physician and use of walk-in clinics in Ontario, Canada: a cross-sectional study

BACKGROUND

Challenges in timely access to one's usual primary care physician and the ongoing use of walk-in clinics have been major health policy issues in Ontario for over a decade. We sought to determine the association between patient-reported timely access to their usual primary care physician or clinic and their use of walk-in clinics.

METHODS

We conducted a cross-sectional study of Ontario residents who had a primary care physician by linking population-based administrative data to Ontario's Health Care Experience Survey, collected between 2013 and 2020. We described sociodemographic characteristics and health care use for users of walk-in clinics and nonusers. We measured the adjusted association between self-reported same-day or next-day access and after-hours access to usual primary care physicians or clinics and the use of walk-in clinics in the previous 12 months.

RESULTS

Of the 60 935 total responses from people who had a primary care physician, 16 166 (weighted 28.6%, unweighted 26.5%) reported visiting a walk-in clinic in the previous 12 months. Compared with nonusers, those who used walk-in clinics were predominantly younger, lived in large and medium-sized urban areas and reported a tight, very tight or poor financial situation. Respondents who reported poor same-day or next-day access to their primary care physician or clinic were more likely to report having attended a walk-in clinic in the previous 12 months than those with better access (adjusted odds ratio [OR] 1.23, 95% confidence interval [Cl] 1.13-1.34). Those who reported being unaware that their primary care physician offered after-hours care had a higher likelihood of going to a walk-in clinic (adjusted OR 1.14, 95% Cl 1.07-1.21).

INTERPRETATION

In this population-based health survey, patient-reported use of walk-in clinics was associated with a reported lack of access to same-day or next-day care and unawareness of after-hours care by respondents' usual primary care physicians. These findings could inform policies to improve access to primary care, while preserving care continuity.

Understanding primary care transformation and implications for ageing populations and health inequalities: a systematic scoping review of new models of primary health care in OECD countries and China

BACKGROUND

Many countries have introduced reforms with the aim of primary care transformation (PCT). Common objectives include meeting service delivery challenges associated with ageing populations and health inequalities. To date, there has been little research comparing PCT internationally. Our aim was to examine PCT and new models of primary care by conducting a systematic scoping review of international literature in order to describe major policy changes including key 'components', impacts of new models of care, and barriers and facilitators to PCT implementation.

METHODS

We undertook a systematic scoping review of international literature on PCT in OECD countries and China (published protocol: https://osf.io/2afym ). Ovid [MEDLINE/Embase/Global Health], CINAHL Plus, and Global Index Medicus were searched (01/01/10 to 28/08/21). Two reviewers independently screened the titles and abstracts with data extraction by a single reviewer. A narrative synthesis of findings followed.

RESULTS

A total of 107 studies from 15 countries were included. The most frequently employed component of PCT was the expansion of multidisciplinary teams (MDT) (46% of studies). The most frequently measured outcome was GP views (27%), with  < 20% measuring patient views or satisfaction. Only three studies evaluated the effects of PCT on ageing populations and 34 (32%) on health inequalities with ambiguous results. For the latter, PCT involving increased primary care access showed positive impacts whilst no benefits were reported for other components. Analysis of 41 studies citing barriers or facilitators to PCT implementation identified leadership, change, resources, and targets as key themes.

CONCLUSIONS

Countries identified in this review have used a range of approaches to PCT with marked heterogeneity in methods of evaluation and mixed findings on impacts. Only a minority of studies described the impacts of PCT on ageing populations, health inequalities, or from the patient perspective. The facilitators and barriers identified may be useful in planning and evaluating future developments in PCT.

What are the top priorities of patients and clinicians for the organization of primary cardiovascular care in Quebec? A modified e-Delphi study

BACKGROUND

Cardiovascular diseases are the leading cause of death and disability worldwide. Little is known about the organizational priorities of patients and clinicians involved in primary cardiovascular care. This study aimed to identify their shared top priorities and explore on which aspects their perspectives differed.

METHODS

A three-round modified online Delphi study was carried out with patients and clinicians in seven academic primary care settings from metropolitan, suburban and small-town areas in Quebec, Canada. Patient partners experienced in the mobilization of their experiential knowledge also participated in the study. Following an "open" round, the items elicited were assessed by a combined rating and ranking approach. Items achieving an initial consensus level ≥70% were reassessed and then rank-ordered based on their final scores. Levels of consensus achieved among patients and clinicians were compared using Fisher's Exact tests.

RESULTS

Thirty panelists completed the study (9 clinic patients, 7 patient partners and 14 clinicians). Out of 41 organizational aspects generated, six top priorities were shared by patients and clinicians. These related to listening and tailoring care to each patient, provision of personalized information, rapid response in the event of a problem, keeping professional training up-to-date, and relational and informational continuity of care. Statistically significant differences were found between patients' and clinicians' perspectives regarding the importance of offering healthy lifestyle and prevention activities at the clinic (lower for patients), timely access to the treating physician (higher for patients), and effective collaboration with specialist physicians (higher for patients).

CONCLUSION

Although their views differ on some organizational aspects, patients and clinicians share a small set of top priorities for primary cardiovascular care that may be transferable to other chronic diseases. These top priorities should remain a central focus of clinical settings, alongside other primary care reform goals.

Who gets access to an interprofessional team-based primary care programme for patients with complex health and social needs? A cross-sectional analysis

OBJECTIVES

To determine whether a voluntary referral-based interprofessional team-based primary care programme reached its target population and to assess the representativeness of referring primary care physicians.

DESIGN

Cross-sectional analysis of administrative health data.

SETTING

Ontario, Canada.

INTERVENTION

TeamCare provides access to Community Health Centre services for patients of non-team physicians with complex health and social needs.

PARTICIPANTS

All adult patients who participated in TeamCare between 1 April 2015 and 31 March 2017 (n=1148), and as comparators, all non-referred adult patients of the primary care providers who shared patients in TeamCare (n=546 989), and a 1% random sample of the adult Ontario population (n=117 753).

RESULTS

TeamCare patients were more likely to live in lower income neighbourhoods with a higher degree of marginalisation relative to comparison groups. TeamCare patients had a higher mean number of diagnoses, higher prevalence of all chronic conditions and had more frequent encounters with the healthcare system in the year prior to participation.

CONCLUSIONS

TeamCare reached a target population and fills an important gap in the Ontario primary care landscape, serving a population of patients with complex needs that did not previously have access to interprofessional team-based care.

STRENGTHS AND LIMITATIONS

This study used population-level administrative health data. Data constraints limited the ability to identify patients referred to the programme but did not receive services, and data could not capture all relevant patient characteristics.

Nursing contributions to virtual models of care in primary care: a scoping review protocol

INTRODUCTION

Since the onset of the COVID-19 pandemic, virtual care has gained increased attention, particularly in primary care for the ongoing delivery of routine services. Nurses have had an increased presence in virtual care and have contributed meaningfully to the delivery of team-based care in primary care; however, their exact contributions in virtual models of primary care remain unclear. The Nursing Role Effectiveness Model, applied in a virtual care and primary care context, outlines the association between structural variables, nursing roles and patient outcomes. The aim of this scoping review is to identify and synthesise the international literature surrounding nurse contributions to virtual models of primary care.

METHODS AND ANALYSIS

The Joanna Briggs Institute scoping review methodology will guide this review. We performed preliminary searches in April 2022 and will use CINAHL, MEDLINE, Embase and APA PsycInfo for the collection of sources for this review. We will also consider grey literature, such as dissertations/theses and organisational reports, for inclusion. Studies will include nurses across all designations (ie, nurse practitioners, registered nurses, practical nurses). To ensure studies capture roles, nurses should be actively involved in healthcare delivery. Sources require a virtual care and primary care context; studies involving the use of digital technology without patient-provider interaction will be excluded. Following a pilot test, trained reviewers will independently screen titles/abstracts for inclusion and extract relevant data. Data will be organised using the Nursing Role Effectiveness Model, outlining the virtual care and primary care context (structure component) and the nursing role concept (process component).

ETHICS AND DISSEMINATION

This review will involve the collection and analysis of secondary sources that have been published and/or are publicly available. Therefore, ethics approval is not required. Scoping review findings will be published in a peer-reviewed journal and presented at relevant conferences, targeting international primary care stakeholders.

Integrating community paramedicine with primary health care: a qualitative study of community paramedic views

BACKGROUND

Community paramedicine (CP) is an emerging model of care that addresses local health needs through programs led by community paramedics; however, CP remains poorly defined and appears to lack systematic integration with the broader health system, specifically primary care, within which it is seated. The purpose of the study was to elucidate the views of community paramedics and their stakeholders in Ontario, Canada, on the topic of integrating CP with the broader health system.

METHODS

This was a retrospective qualitative analysis of a public recording of a CP provincial forum held in Ontario, Canada, in 2017. Forum attendees (paramedics and stakeholders) were invited by email if they had attended a similar provincial forum in the past (no exclusion criteria for attendance). In small- and large-group discussions, attendees discussed their views on how CP could fit into primary care and what medical oversight and acceptance for the profession could involve. A recording of the large-group discussion, which is publicly available, was transcribed and thematically analyzed.

RESULTS

The 89 participants varied in professional affiliation (66% from a paramedic service, n = 59). Among those from paramedic services, 33% were community paramedics (n = 14). Five major themes emerged: defining the role of community paramedics, how CP may integrate with other services, how to garner support for CP, where standardization is needed and possible oversight structures.

INTERPRETATION

Community paramedics and their stakeholders have insights into barriers and facilitators for integration with the health system. These study findings could help inform the integration of health and social services in Ontario with a consideration for the unique position and potential of community paramedics.

Care in the Community: Opportunities to improve cancer screening uptake for people living with low income

Despite organized provincial cancer screening programs, people living with low income consistently have lower rates of screening in Ontario, Canada than their more socioeconomically advantaged peers. We previously published results of a two-phase, exploratory qualitative study involving both interviews and focus groups whose objective was to integrate knowledge of people living with low income on how to improve primary care strategies aimed at increasing cancer screening uptake. In the current paper, we report previously unpublished findings from that study that identify how taking a community outreach approach in primary care may lead to increased cancer screening uptake among people living with low income. Participants told us that they saw value in a community outreach approach to cancer screening. They recommended specific actionable approaches, in particular, mobile community-based screening and community information sessions, and recommended taking an ethno-specific lens depending on the communities being targeted. Participants expressed a desire for primary care providers to go out into the community to learn more about the whole patient, such as could be achieved with home visits, but they simultaneously believed that this may be challenging in urban settings and in the context of perceived physician shortages. Models of primary care that provide support to an entire local community and provide some of their services directly in that community may have a meaningful impact on cancer screening for socially marginalized groups.

Systems thinking in health technology assessment: a scoping review

OBJECTIVE

Our objective was to assess how, and to what extent, a systems-level perspective is considered in decision-making processes for health interventions by illustrating how studies define the boundaries of the system in their analyses and by defining the decision-making context in which a systems-level perspective is undertaken.

METHOD

We conducted a scoping review following the Joanna Briggs Institute methodology. MEDLINE, EMBASE, Cochrane Library, and EconLit were searched and key search concepts included decision making, system, and integration. Studies were classified according to an interpretation of the "system" of analysis used in each study based on a four-level model of the health system (patient, care team, organization, and/or policy environment) and using categories (based on intervention type and system impacts considered) to describe the decision-making context.

RESULTS

A total of 2,664 articles were identified and 29 were included for analysis. Most studies (16/29; 55%) considered multiple levels of the health system (i.e., patient, care team, organization, environment) in their analysis and assessed multiple classes of interventions versus a single class of intervention (e.g., pharmaceuticals, screening programs). Approximately half (15/29; 52%) of the studies assessed the influence of policy options on the system as a whole, and the other half assessed the impact of interventions on other phases of the disease pathway or life trajectory (14/29; 48%).

CONCLUSIONS

We found that systems thinking is not common in areas where health technology assessments (HTAs) are typically conducted. Against this background, our study demonstrates the need for future conceptualizations and interpretations of systems thinking in HTA.

Inequities in the delivery of mental health care: a grounded theory study of the policy context of primary care

BACKGROUND

Strengthening capacity for mental health in primary care improves health outcomes by providing timely access to coordinated and integrated mental health care. The successful integration of mental health in primary care is highly dependent on the foundation of the surrounding policy context. In Ontario, Canada, policy reforms in the early 2000's led to the implementation of a new interprofessional team-model of primary care called Family Health Teams. It is unclear the extent to which the policy context in Ontario influenced the integration of mental health care in Family Health Teams emerging from this period of policy reform. The research question guiding this study was: what were key features of Ontario's policy context that influenced FHTs capacity to provide mental health services for mood and anxiety disorders?

METHODS

A qualitative study informed by constructivist grounded theory. Individual interviews were conducted with executive directors, family physicians, nurse practitioners, nurses, and the range of professionals who provide mental health services in interprofessional primary care teams; community mental health providers; and provincial policy and decision makers. We used an inductive approach to data analysis. The electronic data management programme NVivo11 helped organise the data analysis process.

RESULTS

We conducted 96 interviews with 82 participants. With respect to the contextual factors considered to be important features of Ontario's policy context that influenced primary care teams' capacity to provide mental health services, we identified four key themes: i) lack of strategic direction for mental health, ii) inadequate resourcing for mental health care, iii) rivalry and envy, and, iv) variations across primary care models.

CONCLUSIONS

As the first point of contact for individuals experiencing mental health difficulties, primary care plays an important role in addressing population mental health care needs. In Ontario, the successful integration of mental health in primary care has been hindered by the lack of strategic direction, and inconsistent resourcing for mental health care. Achieving health equity may be stunted by the structural variations for mental health care across Family Health Teams and across primary care models in Ontario.

Comparing public policies impacting prescribing and medication management in primary care in two Canadian provinces

The challenges of polypharmacy and inappropriate prescribing are recognized internationally. This study synthesizes and compares the policies related to these issues introduced in Canada's two most populous provinces - Ontario and Quebec - over the first two decades of the 21st century. Drawing on policy documents and consultations with experts, we found that while medication management to address polypharmacy and inappropriate prescribing has not been an explicit and consistent policy target in either province, some policy changes sought to directly or indirectly impact medication management. These changes include the introduction of primary care teams that include pharmacists, the introduction of a medication review performed by pharmacists (in Ontario), increased emphasis on quality improvement with some attention to potentially inappropriate medications (specifically opioids in Ontario), and investments in information technology to improve communication across providers and move toward electronic prescribing to improve medication safety and appropriateness. Despite growing evidence of the problem of polypharmacy and inappropriate prescribing, there has been limited policy attention targeting these problems directly, and policy changes with potential to improve prescribing and medication management may not have been fully realized. Further research to evaluate the impact of these changes on provider behaviours, and on patient outcomes, warrants attention.

"Top-Three" health reforms in 31 high-income countries in 2018 and 2019: an expert informed overview

BACKGROUND

High-income countries continuously reform their healthcare systems. Often, similar reforms are introduced concomitantly across countries. Although national policymakers would benefit from considering reform experiences abroad, exchange is limited. This paper provides an overview of health reform trends in 31 high-income countries in 2018 and 2019, i.e., before Covid-19.

METHODS

Information was collected from national experts from the Health Systems and Policy Monitor network. Experts were asked to report on the three "top" national health reforms 2018 and 2019. In 2019, they provided an update of 2018 reforms. Reforms were assigned to one of 11 clusters and identified as one of seven different reform types.

RESULTS

81 reforms were reported in 28 countries in 2018. 44/81 went to four clusters: 'insurance coverage & resource generation', 'governance', 'healthcare purchasing & payment', and 'organisation of hospital care'. In 2019, 86 reforms in 30 countries were reported. 48/86 fell under 'organisation of primary & ambulatory care', 'governance', 'care coordination & specialised care', and 'organisation of hospital care'. Most 2018 reforms were reported ongoing in 2019; 27 implemented; seven abandoned. Health agency-led reforms were implemented most frequently, followed by central government-legislated reforms.

CONCLUSIONS

Policymakers can leverage international experience of distinct reform approaches addressing similar challenges and similar approaches to address distinct problems. Such knowledge may help inspire or support future successful health reform processes.

An implementation history of primary health care transformation: Alberta's primary care networks and the people, time and culture of change

BACKGROUND

Primary care, and its transformation into Primary Health Care (PHC), has become an area of intense policy interest around the world. As part of this trend Alberta, Canada, has implemented Primary Care Networks (PCNs). These are decentralized organizations, mandated with supporting the delivery of PHC, funded through capitation, and operating as partnerships between the province's healthcare administration system and family physicians. This paper provides an implementation history of the PCNs, giving a detailed account of how people, time, and culture have interacted to implement bottom up, incremental change in a predominantly Fee-For-Service (FFS) environment.

METHODS

Our implementation history is built out of an analysis of policy documents and qualitative interviews. We conducted an interpretive analysis of relevant policy documents (n = 20) published since the first PCN was established. We then grounded 12 semi-structured interviews in that initial policy analysis. These interviews explored 11 key stakeholders' perceptions of PHC transformation in Alberta generally, and the formation and evolution of the PCNs specifically. The data from the policy review and the interviews were coded inductively, with participants checking our emerging analyses.

RESULTS

Over time, the PCNs have shifted from an initial Frontier Era that emphasized local solutions to local problems and featured few rules, to a present Era of Accountability that features central demands for standardized measures, governance, and co-planning with other elements of the health system. Across both eras, the PCNs have been first and foremost instruments and supporters of family physician authority and autonomy. A core group of people emerged to create the PCNs and, over time, to develop a long-term Quality Improvement (QI) vision and governance plan for them as organizations. The continuing willingness of both these groups to work at understanding and aligning one another's cultures to achieve the transformation towards PHC has been central to the PCNs' survival and success.

CONCLUSIONS

Generalizable lessons from the implementation history of this emerging policy experiment include: The need for flexibility within a broad commitment to improving quality. The importance of time for individuals and organizations to learn about: quality improvement; one another's cultures; and how best to support the transformation of a system while delivering care locally.