Interprofessional collaboration between general physicians and emergency department services in Belgium: a qualitative study

Abstract

Introduction: The use of emergency department (ED) services has known a significant rise in the past decade. Organizational factors, such as the models of after-hours primary medical care services, and the shortage of general practitioners (GPs) could explain this phenomena. But also demographic and societal elements combined with the problem of patient’s ‘inappropriate visits to the ED. In order to ensure continuity of care for patients, collaboration between GPs and EDs becomes increasingly essential. Not to mention the benefit of this collaboration for the healthcare system in terms of efficacy and efficiency.This papers explores positive experiences of collaboration between GPs and ED teams in Brussels and the French speaking regions of Belgium, with the objectives of 1) identifying the main concepts related to IC that are highly valued by actors; and 2) analyzing forces and opportunities of the Belgian context in terms of IC. Focusing on positive experiences is inspired from the Appreciative Inquiry (AI) philosophy which is based on the assumption that every organization has something that works well and these strengths can be the starting point to create a positive change.Methods: A series of eight focus groups (FG) with GPs and ED teams was conducted in Brussels and different French speaking regions between September 2014 and December 2015. FG lasted one and a half hours on average. Participants’ number varied between 6 and 12 per FG. They were audio recorded and transcribed verbatim. An interview guide was designed based on the first two phases of AI, “discovery and dream”. Transcripts were analyzed thematically using an inductive content analysis technique.Results: Findings showed that a positive experience of collaboration is mainly related to a high level of communication. Both GPs and EDs attach great importance to clear, timely, and accurate written reports, but also to oral communication. Phone calls are highly valued as they allow actors to interact directly, and negotiate the patient plan of care. Mutual acquaintanceship is another component of IC. Actors agree that knowing each other and being able to put a face to a name optimizes contact, enhances relationships and strengthens trust. Trust is also the result of previous experiences. It is manifested by seeking advice from each other and making joint decisions. Another finding is about power. A positive experience of power is mainly characterized by a relationship of equality without any dominance behavior. It shows in respectful and professional attitudes towards each other. Role clarification is also of particular importance. Knowing one’s own role and that of others and fulfilling that role is considered as a valuable lever for collaboration. It supposes that actors are aware of each other training, thus more confident in the competencies of the others. It also improves the referral process. The patient himself plays a major role in enhancing IC and can be the driving force in communication between actors. As for the political environment and the healthcare system in general, they don’t seem to play a significant role in promoting collaboration between GPs and EDs. With the absence of integration policies, data and information exchange system remains poorly developed; there are no incentive measures to encourage collaboration; no gatekeeping process; the out of hours GPs services are problematic for both parties; and the fee-per-service payment and the legislation on both parties financing encourage competition. Finally, actors’ priorities, in order to achieve better collaboration, include better communication and mutual acquaintanceship.Discussion: Opportunities for enhancing IC in the Belgian context include a recent report from the Belgian healthcare knowledge center addressing the organization and payment of ED services in Belgium and highlighting the necessity of increased collaboration between EDs and GPs. Although controversial, the report is definitely a starting point of negotiation toward better IC. Also the recent federal plan aiming at developing integrated and patient centered care for chronic patients by developing pilot projects which experiment and evaluate models of integration. As for the forces, they lie in the fact that mutual acquaintanceship happens informally, despite the lack of organized activities, and that actors are aware of the benefits of IC and ready to engage in a better relationship.Conclusion: In terms of cost-efficiency, the performance of the Belgian healthcare system remains poor. Several initiatives aiming at coordinating care between hospitals and primary care have been established. But until today, only rare strategies target the ED specifically. In the future, strategies to enhance collaboration should be seriously investigated if we aspire to integrating efficiently the different healthcare providers.