Table VIII Constructs of the inner...

Table VIII

Constructs of the inner setting according to the CFIR framework distinguishing high-performing cases from lower ones

	Low-performing cases		High-performing cases
	Case 1	Case 2	Case 3	Case 4
Inner setting
1.1 Networks and communication within services of the HSSC	Communication/meetings Between GACO personnel Informal meeting to address common work issues between clerk and GACO nurse Trying to improve work procedures (e.g. clerk work)	Communication/meetings Between GACO personnel Some meetings between GACO staff Still trying to improve work procedures (e.g. clerk work)	Communication/meetings Between GACO personnel Good collaborative practice and communication within GACO staff and with the medical coordinator: to take decisions about strategies and about special cases; to ensure a work continuity: e.g. using their initials to leave comments in the system Formal communication strategy developed through a computer-based system online, to perform a quick pre-prioritization process for patients with special needs and reduce delays	Communication/meetings Between GACO personnel Good collaborative practice and communication between GACO staff to accelerate registration and evaluation (e.g. monthly meetings) and with medical coordinator Communication system instituted either via formal or informal procedures: using staff initials and developing symbol systems and codes between nurse and clerk to identify priority patients quickly and enhance their access to FP
	Between GACO personnel and HSSC personnel Informal communication mechanisms between GACO personnel and other HSSC personnel to facilitate the process of discharging a patient	Between GACO personnel and HSSC personnel Collaboration on some occasions with HSSC personnel	Between GACO personnel and HSSC personnel Communication highly developed: several meetings within the HSSC	Between GACO personnel and other HSSC personnel Tight link between GACO with other services of the HSSC to give care to patients while waiting on GACO
1.2 Networks and communication in between the services of the LHN	Between GACO staff and clinics, health professionals Poor communication and collaboration GACO does not work with all clinics of the LHN	Between GACO staff and clinic, health professionals Poor/very little communication, collaboration FP working in clinics not being adequately informed about patients’ waiting lists, changes in GACO’s procedures Some contacts between GACO nurse and FP: facilitates referral of some cases, patients’ transfer in case of FP’s retirement	Between GACO staff and clinic, health professionals Inter professional communication, collaboration well developed Sharing a medical file on patients referred from GACO: facilitate their follow up with patient, increase FP will to participate in GACO Meeting with new FP before starting their practice and referring them to GACO to ask for new patients; with several FP to ask them to take patients from GACO	Between GACO staff and clinic, health professionals Inter professional communication, collaboration well developed Good contact between GACO clerk, nurse and some clinics facilitates patients care in case of emergency Tight link between GACO and other services of the HSSC to provide care to patients while they are on the waiting list Sharing a complete form on patients with health assessment (evaluation tool) with clinics Meetings and discussions by GACO staff with clinics to resolve communication’s difficulty Sometimes poor communication between GACO staff–clinics–FP: (e.g. follow up by GACO staff with clinics to know if patients have been refused) Collaboration of GACO nurse with other health professionals: nurse who registers homeless patients collaborates/meets the health professional to make the GACO well-known, to enhance taking care of homeless people
	Between clinics Most clinics of territory function solitarily thus hampering their participation in GACO Most clinics of the LHN do not collaborate, no networking between the different LHN	Between clinics Links not mentioned	Between clinics Well-established links between clinics and services Communication with RDGM, FMG, HSSC, all FP: important to maintain for GACO Good link between all the services of the different territories: meeting every month at regional level and several meetings within the services of HSSC	Between clinics Tight link between services of the HSSC to provide care to patients waiting on the GACO
Readiness for implementation
2. Leadership engagement	No specific champion mentioned, unknown by some FP Medical coordinator: not very aggressive in his interventions, to invite his colleagues (FP) to participate in GACO Traditional role fulfilled by medical coordinator: providing support when needed, dealing with problematic FP	Involvement of a champion FP Active medical coordinator: in managing patients’ requests, solving problems, taking many vulnerable patients Absence of medical coordinator during a period of time: limited capacity of manager fulfilling this role to recruit FP Procedure to improve GACO’s functioning not done, is still on hold due to the leader’s departure	Involvement of a champion FP Medical coordinator highly involved in GACO implementation: played a major role in solving problems, encouraging FP to attach patients, in managing patients’ requests and attaching many vulnerable patients Proactive leader: creative initiatives to offer alternative health services	Involvement of two emergent champions (not formally appointed) One young FP highly involved (attached 400 vulnerable patients-babies from GACO/year; very well known by others) Nurse: very proactive, keen on reducing long waiting times for patients, took the responsibility to create adaptive strategies to leverage resources Lack of involvement of medical coordinator, of playing active role in implementation No leadership exerted by him: described as not motivated to explain the GACO’s functioning to other FP Unknown by some FP
3. Available resources	Lack of human resources, financial resources No extra support from the HSSC in GACO implementation Presence of one nurse in GACO who has to perform many tasks, 3 working days instead of 5 due to financial budgets cut Clerk will be working alone because nurse is leaving Lack of resources, support in clinics for FP to take more patients from GACO No strategy adopted to counteract this barrier	Lack of human, financial resources, turnover of staff, technology difficulty Lack of staff, FP on the territory to participate in GACO, to answer the patients’ needs Important staff turnover: lack of clerk’s stability leads to a delay Not enough funds for recruiting more human resources Technologic resources: SIGACO was not linked to Quebec Health Insurance Board (RAMQ) No strategy adopted to counteract this barrier	Lack of human resources, lack of time, turnover of staff, Technology difficulty Not enough human resources to manage registration by phone, due to many requests Not enough FP to take patients from GACO, to answer to all patients’ requests Not enough space also Access to Quebec Health Insurance Board (RAMQ) to check patient attachment is not easy for GACO staff Adoption of strategy to optimize resources Pre-prioritization done by computer to overcome lack of human resources Mobilizing a nurse clinician to help GACO’s staff (to prioritize patients, check their status in the medical insurance database) Suggestions made: double the staff to be able to run the GACO	Lack of human, financial resources, lack of time, turnover of staff, technology difficulty Not enough resources to manage the numerous requests for GACO Not enough FP to respond to demand (many requests) Funds constrains to hire several nurses Adoption of strategy to optimize resources Optimal utilization of resources: full-time clerk and several nurses not dedicated to prioritization but will help when they have free time in their agenda Training many nurses for evaluation in GACO during free time on their schedule in order not to depend on only one person Suggestions made: dedicate one nurse to answer requests through one phone line

	Low-performing cases		High-performing cases
	Case 1	Case 2	Case 3	Case 4
Inner setting
1.1 Networks and communication within services of the HSSC	Communication/meetingsBetween GACO personnel Informal meeting to address common work issues between clerk and GACO nurse Trying to improve work procedures (e.g. clerk work)	Communication/meetingsBetween GACO personnel Some meetings between GACO staff Still trying to improve work procedures (e.g. clerk work)	Communication/meetingsBetween GACO personnel Good collaborative practice and communication within GACO staff and with the medical coordinator: to take decisions about strategies and about special cases; to ensure a work continuity: e.g. using their initials to leave comments in the system Formal communication strategy developed through a computer-based system online, to perform a quick pre-prioritization process for patients with special needs and reduce delays	Communication/meetingsBetween GACO personnel Good collaborative practice and communication between GACO staff to accelerate registration and evaluation (e.g. monthly meetings) and with medical coordinator Communication system instituted either via formal or informal procedures: using staff initials and developing symbol systems and codes between nurse and clerk to identify priority patients quickly and enhance their access to FP
	Between GACO personnel and HSSC personnel Informal communication mechanisms between GACO personnel and other HSSC personnel to facilitate the process of discharging a patient	Between GACO personnel and HSSC personnel Collaboration on some occasions with HSSC personnel	Between GACO personnel and HSSC personnel Communication highly developed: several meetings within the HSSC	Between GACO personnel and other HSSC personnel Tight link between GACO with other services of the HSSC to give care to patients while waiting on GACO
1.2 Networks and communication in between the services of the LHN	Between GACO staff and clinics, health professionals Poor communication and collaboration GACO does not work with all clinics of the LHN	Between GACO staff and clinic, health professionals Poor/very little communication, collaboration FP working in clinics not being adequately informed about patients’ waiting lists, changes in GACO’s procedures Some contacts between GACO nurse and FP: facilitates referral of some cases, patients’ transfer in case of FP’s retirement	Between GACO staff and clinic, health professionals Inter professional communication, collaboration well developed Sharing a medical file on patients referred from GACO: facilitate their follow up with patient, increase FP will to participate in GACO Meeting with new FP before starting their practice and referring them to GACO to ask for new patients; with several FP to ask them to take patients from GACO	Between GACO staff and clinic, health professionals Inter professional communication, collaboration well developed Good contact between GACO clerk, nurse and some clinics facilitates patients care in case of emergency Tight link between GACO and other services of the HSSC to provide care to patients while they are on the waiting list Sharing a complete form on patients with health assessment (evaluation tool) with clinics Meetings and discussions by GACO staff with clinics to resolve communication’s difficulty Sometimes poor communication between GACO staff–clinics–FP: (e.g. follow up by GACO staff with clinics to know if patients have been refused) Collaboration of GACO nurse with other health professionals: nurse who registers homeless patients collaborates/meets the health professional to make the GACO well-known, to enhance taking care of homeless people
	Between clinics Most clinics of territory function solitarily thus hampering their participation in GACO Most clinics of the LHN do not collaborate, no networking between the different LHN	Between clinics Links not mentioned	Between clinics Well-established links between clinics and services Communication with RDGM, FMG, HSSC, all FP: important to maintain for GACO Good link between all the services of the different territories: meeting every month at regional level and several meetings within the services of HSSC	Between clinics Tight link between services of the HSSC to provide care to patients waiting on the GACO
Readiness for implementation
2. Leadership engagement	No specific champion mentioned, unknown by some FPMedical coordinator: not very aggressive in his interventions, to invite his colleagues (FP) to participate in GACOTraditional role fulfilled by medical coordinator: providing support when needed, dealing with problematic FP	Involvement of a champion FP Active medical coordinator: in managing patients’ requests, solving problems, taking many vulnerable patientsAbsence of medical coordinator during a period of time: limited capacity of manager fulfilling this role to recruit FPProcedure to improve GACO’s functioning not done, is still on hold due to the leader’s departure	Involvement of a champion FP Medical coordinator highly involved in GACO implementation: played a major role in solving problems, encouraging FP to attach patients, in managing patients’ requests and attaching many vulnerable patients Proactive leader: creative initiatives to offer alternative health services	Involvement of two emergent champions (not formally appointed) One young FP highly involved (attached 400 vulnerable patients-babies from GACO/year; very well known by others) Nurse: very proactive, keen on reducing long waiting times for patients, took the responsibility to create adaptive strategies to leverage resourcesLack of involvement of medical coordinator, of playing active role in implementation No leadership exerted by him: described as not motivated to explain the GACO’s functioning to other FP Unknown by some FP
3. Available resources	Lack of human resources, financial resources No extra support from the HSSC in GACO implementation Presence of one nurse in GACO who has to perform many tasks, 3 working days instead of 5 due to financial budgets cut Clerk will be working alone because nurse is leaving Lack of resources, support in clinics for FP to take more patients from GACO No strategy adopted to counteract this barrier	Lack of human, financial resources, turnover of staff, technology difficulty Lack of staff, FP on the territory to participate in GACO, to answer the patients’ needs Important staff turnover: lack of clerk’s stability leads to a delay Not enough funds for recruiting more human resources Technologic resources: SIGACO was not linked to Quebec Health Insurance Board (RAMQ) No strategy adopted to counteract this barrier	Lack of human resources, lack of time, turnover of staff, Technology difficulty Not enough human resources to manage registration by phone, due to many requests Not enough FP to take patients from GACO, to answer to all patients’ requests Not enough space also Access to Quebec Health Insurance Board (RAMQ) to check patient attachment is not easy for GACO staff Adoption of strategy to optimize resources Pre-prioritization done by computer to overcome lack of human resources Mobilizing a nurse clinician to help GACO’s staff (to prioritize patients, check their status in the medical insurance database) Suggestions made: double the staff to be able to run the GACO	Lack of human, financial resources, lack of time, turnover of staff, technology difficulty Not enough resources to manage the numerous requests for GACO Not enough FP to respond to demand (many requests) Funds constrains to hire several nurses Adoption of strategy to optimize resources Optimal utilization of resources: full-time clerk and several nurses not dedicated to prioritization but will help when they have free time in their agenda Training many nurses for evaluation in GACO during free time on their schedule in order not to depend on only one person Suggestions made: dedicate one nurse to answer requests through one phone line

Notes: FP, family physician; GACO, Guichets d’Accès aux Clienteles Orphelines; FMG, Family Medicine Group; HSSC, Health Social Services Centers; LHN, Local Health Network; QFGP, Quebec Federation of General Practitioners; RAMQ, Régie d’Assurance Maladie du Quebec (Quebec Health Insurance Board); RDGM, Regional Department of General Medicine; SIGACO, database

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