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Table 4 Factors that contributed to program implementation success or failure in Ontario

From: Building integrated, adaptive and responsive healthcare systems – lessons from paramedicine in Ontario, Canada

Contributing Factor Illustrative Quotes
Interprofessional trust and understanding: Role negotiation and role sharing between different professions. Time spent building trust and overcoming territorialism. “I think the first step is building these relationships, building the rapport, building the confidence and the trust. You know, I call it like an interprofessional trust and connection. Because without that, you can put the system in place, it’s not going to work.” (Participant 5; Paramedic)
“I think we need to stop thinking of ourselves from the provider perspective and from what we do, and reverse that view from the patient perspective. And that’s where the integration comes in. It shouldn’t be paramedics do X and nursing does Y and physicians do Z and occupational therapy does whatever, and nobody talks to each other.” (Participant 6; Paramedic)
Key role for physicians in providing guidance, consultation, delegating medical acts, acting as a champion for programs amongst other physicians. Mechanisms to reimburse physicians for consultation. “But I think it would only allow you to expand your own profession in a direction where physicians like myself aren’t, right? I don’t want to drive your profession, I want to work with you to drive your profession, right. And I think we need to build that.” (Participant 9; Physician)
“Because we know that physicians listen to physicians better, you’re championing the program. You’re like, this is really worth it, we should do this for this reason, you’re trying to kind-of convince the other people and champion it in any way so that it’s more of a successful program.” (Participant 17; Physician)
Organizational and personal networks: Multiple organizations regularly meet and discuss issues. Paramedic representation at multiple “tables” – municipal, LHIN, hospital, OHT. Personal relationships between managers of local agencies. “So now we’re involved in the OHT. But before that even came about there were, the LHIN had regional anchor tables, right. And so we were participants in an anchor table. And even before that the chief had brought together... public health made it one of their, I think it was for 2012, made it one of public health goals to look at sort of community paramedicine and brought a bunch of different disciplines to the table.” (Participant 25; Paramedic)
“[Region] is unique in that regards, in that we kind of all know each other. So good and bad. But you do know, like, who all the players are, right? So I have a fairly close relationship with the manager for Home and Community Care for this area where we work.” (Participant 4; Paramedic)
Buy-in from the frontline: Providing career choice, selecting the “right” people for new roles, involving frontline providers in program design, positive or negative feedback that reinforces (or discourages) new practices. “But, but kind of my takeaway from that is that you really need a willing and engaged workforce with high morale and feeling like they’re making a difference, and they’re seeing it, which is then kind of makes you want to do more, right?” (Participant 17; Physician)
“I’m really grateful that we have those two individuals, because if you get the wrong person in that role, it could be very detrimental to the program.” (Participant 18; Paramedic)
Information and data sharing: Challenges with access to clinical viewers, navigating privacy law, siloed patient record systems, paramedics not legally seen as health providers. “The biggest issue that’s out there with healthcare in general is the information sharing and privacy and the PHIPA, which is often misunderstood, right? And so there’s always the questions of whether or not that we can share information with our stakeholders and vice versa. And we all have different software platforms.” (Participant 13; Paramedic)
“Privacy committee of [family health team] were adamant: nope, we’re concerned about opening up to other people to be in our health record. And this persona that you believe the record is yours, like your property. It’s the patient’s record. We’re all healthcare professionals.” (Participant 10; Nursing, Occupational or Physical Therapist)
“And that, again, like we have these hurdles, we’re trying to get access to ConnectingOntario, but we’re not seen as either - we’re not a healthcare provider.” (Participant 15; Paramedic)
Education, knowledge and decision-making: Systems for paramedic education and learning, both entry-to-practice and ongoing; shortcomings in existing systems (e.g., staff hours, curriculum). “So, for example, post secondary institutions to support training, development, and accreditation of these roles. We don’t have that in place. And we’ve seen that because we’re currently trying to figure out: how do we better align these professional development programs that we’re seeing throughout the province.” (Participant 26; Paramedic)
“It’s a culture divide within paramedicine. So, older paramedics compared to younger paramedics, I find that education is lacking for the older senior paramedics, just in their initial education becoming a paramedic, there wasn’t a lot of focus on kind of substance use as well as mental health and kind of like, the whole biopsychosocial spectrum for that matter.” (Participant 14; Paramedic)
Regulatory limitations of paramedic practice: Prescribed scope-of-practice in law, requirements to transport to hospital-based services. “And the problem - I think across Canada, more so in Ontario based on some of the laws - is that paramedics respond, as you’re aware, they have a choice to either transport to hospital or patients need to refuse care. There wasn’t any other sort of mechanism to make choices around that.” (Participant 9; Physician)
Liability and risk: Multiple actors – Ministry of Health, municipalities, individual physicians and paramedics – navigating concerns about liability and risk of adverse events. “And I think part of the other issue was our medical director worked for them, is working for the region, right? And we’re working for the region. And then we have risk and legal over there who - and I think there were questions on does that - does she need more insurance? And who’s paying for that?” (Participant 15; Paramedic)
“The other thing is, there’s this fear of risk and liability which is often, I think, misplaced, but it comes from the culture and the education. Right from day one when they start receiving education right through their career, it’s hammered into them that, you know, they have to cover themselves in case something goes wrong.” (Participant 13; Paramedic)
Leadership and power: Key leaders in influential positions that support or promote innovation. “So from the community paramedic perspective, the best thing that ever happened to the group up here was they found the right person as leading the team that really gets it.” (Participant 10; Nursing, Occupational or Physical Therapist)
“I cannot under emphasize the importance of having a leader like [name], that is innovative, forward thinking, supportive, and willing to think outside the box and support growth and innovation the way he does. That was probably, of all of this, the most critical piece. Because we could just as easily find ourselves with a leadership team that, you know, is very much by-the-book.” (Participant 25; Paramedic)
Funding: Inconsistent, transient, rolling funding envelopes; programs would have to shut down, re-staff, change shape; political funding priorities. “We didn’t know, you know, we don’t find out until two or three weeks into the next fiscal year if we even have base funding. And that just seems to be an overall theme that, you know, no one really knows where the funding is coming from or what pocket of funding we’re going to be part of.” (Participant 1; Paramedic)
“The biggest problem with it is that it was that short-term funding. So it would take us a couple months to get off the ground, build our clients, get the referrals basis, and then funding would end a very short time after that … probably one of the worst things was that after you get it up and running, you lose the funding and then you completely start over at ground zero the next, next pilot. You have to try and rebuild all those networks and build those referral pathways and things like that.” (Participant 16; Paramedic)