CFIR Domains | Enablers | Barriers |
---|---|---|
I: Intervention Characteristics | Buy-in from medical professional organizations Good data and research to understand impact of changes in system Neutral funding models that link funding to activities of whole team on a per patient basis Independent income generation, not dependent on their activities or those of colleagues Resourcing and funding for interprofessional practice and related initiatives | Unstable, inadequate, or lack of long-term funding or reimbursement models Space & equipment covered by income of a specific provider |
II: Outer Setting | Client-centered approaches (i.e., assessing patient/community characteristics and needs) Involving patient and family in care planning and delivery Patients willing to receive care from teams. Multi-component models that involve patient education, systematic follow-up, medication adherence GP networking in community to establish contacts with community partners (e.g., social services, hospitals) Managers supporting integrating care (e.g., care coordination, connecting to social services, nursing homes, prevention resources) Inter-organizational collaboration, including service integration and coordinating care for patients with complex needs GPs in alternate payment plans (APPs) may be more incentivized to participate in collaborative activities than fee for service plans. Health professional regulatory bodies incorporating interprofessional competencies into licensing requirements Incorporating interprofessional education into academic curricula for healthcare professional programs, pre- and post- licensure Graduate level education for advanced practice nurses System-level collaboration and policies (i.e., legislative and regulatory reforms) which may set targets for interprofessional care or introduce non-physician professionals into teams | Lower compensation and benefits for teams compared to hospitals and private sector results in poor recruitment and retention Different remuneration systems for different professionals (e.g., referrals from GPs vs. NPs) When funding or compensation does not facilitate participation in team (e.g., meetings discussing patients) Salaries that originate from different funding sources Fee for service payment models, which reward interprofessional isolation. Top-down policies that require physician authority or decision-making Team members lack competency in interprofessional collaboration due to lack of/inadequate interprofessional training Difficulty in engaging with wider community in rural/remote areas when practitioners are new |
III: Inner Setting | Move away from physician-driven care; include nurse practitioners on team Adopting a “whole system” approach by involving non-clinical staff and clerical staff on team Ensure there is an established team leader/manager responsible for managing and facilitating collaboration and day-to-day activities Single-handed governance structures, in place of a partnerships, are positively associated with team climate Clinics operating under a board of directors Integrating both bottom-up and top-down governance associated with heightened efficiency and coordination Developing new organizational infrastructure crucial for care delivery Tech supports (e.g., EMRs, computerized message & booking, telehealth) facilitate collaborative decision making and information sharing Standardize documentation and tools (e.g., integrated care pathways, common patient charts, interprofessional care plans) Encourage information sharing, task delegation, and supportive communication through: weekly scheduled interprofessional team meetings, frequent and reciprocated ad-hoc communications (e.g., clinic huddles) Meetings include procedures for negotiation, decision making and conflict management and resolution Clearly defining roles and understanding roles and respective scopes of practice Set interprofessional guidelines (e.g., referral mechanisms between members) Interprofessional case conferences allows opportunity to collaborate Non-hierarchical organizational structure that encourages equality, mutual respect, low levels of conflict, willingness to cooperate and collaborate Balance between group culture, hierarchy and focus on efficiency and achievement Balanced power relationships through shared leadership, decision making, authority and responsibility Identify and adjust power imbalances to build mutually supportive workplaces Financial incentives based upon unique collaborative care demands (e.g., after-hours services, compilation of care plans) Feeling supported and formally recognized for performance Opportunities for all staff to receive bonuses based upon target achievement A clear vision and well-defined goals that have been collectively identified contribute to a shared sense of purpose Processes for group decision making and problem solving promote shared purpose amongst the team Colocation leads to greater mutual understanding, increased role clarity and superior care delivery Educating staff in interprofessional care on the job (e.g., social and organizational training to mitigate power dynamics and training on co-workers’ roles) Offering learning opportunities and leadership training courses to support collaboration Clearly explained team processes, policies, and procedures as well as accessible and intuitive documentation | Lack of clear/inadequate leadership, and system-level leadership Ambiguous roles, lack of understanding of the knowledge and skills of different professionals, and concerns about professional scope and liability Lack of training or experience required to evolve into facilitators of collaboration Physical separation creates a symbolic barrier and reinforces perceived divisions Insufficient workspace or profession-specific spaces negatively impact communication, workflow, and team cohesion Lack of training or educational opportunities Insufficient time in the day to engage in and share reflections and learnings, instill a trusting environment Insufficient human resources impact the implementation of initiatives to improve collaborative care |
IV: Characteristics of Individuals | Belief in, or positive attitude towards, the concept of collaboration The ability to be flexible in one’s professional role within the team GPs accommodate the new skill mixes on a team and acknowledge the potential benefit of non-physician/patient interactions Collaborative skills possessed by individuals within the team | Opposition or disagreement among team members on the potential value of interprofessional initiatives and education, and the impact on patients Opposing interests, values, and beliefs and interprofessional conflict Concern or territoriality around one’s role within the team, with a shift in attitude needed to allow all appropriate team members to have meaningful patient interactions |
V: Process | Plan human health resources in a manner that encourages collaboration and coordination Establish human resource plans that allow time for staff to participate in interprofessional activities Reduced team turnover to optimize growth To foster future collaboration, allow opportunities for students from different professions/programs to engage with one another Promote greater interprofessional networking Management structures and system level foundations that are explicitly collaborative and support local leadership and team development & processes Engage and develop interprofessional leaders among the point-of-care health professional Developing and having team champion(s) and facilitators within the team to integrate team actions, facilitate team building External accountability like focusing on quality through audits or other processes and motivate a collaborative approach to problem solving Monitoring and evaluation are a method to overcome system level barriers to interprofessional communication Team members reflecting on their practice and sharing informal feedback with colleagues about their interprofessional work | Limited human resource planning Physician reluctance to collaboration Reluctance of patients to see multiple providers Difficulty reporting relevant outcomes measures of interprofessional education and practice |