Supporting rural health services through regional networks: Observations of a formalized model

Background

The foundational, organizing structure of the RSON initiative is the creation and maintenance of robust clinical and administrative relationships which coalesce into health service delivery networks. Networks in this instance are defined as the intentional collaboration of entities within healthcare delivery (between rural sites and regional and tertiary centres, interprofessional networks within communities and peer networks across communities) working together to achieve the common goal of improved surgical and obstetrical health services. They are predicated on optimizing health outcomes through increased efficiency and enhanced learning and have emerged as a viable health service delivery option. ⁴

The RSON initiative was predicated on evidence which demonstrated that increased efficiency, enhanced learning, better client services and improved ability to address challenges are effective mechanisms to solve complex social and population health issues.^4,11 These strategies are actualized primarily through taking advantage of both increased resources and human capacity. ¹² Further, the inherently decentralized nature of networks was deemed congruent with the distributed nature of rural health services ⁷ and recognized to be an effective structure to stabilize local rural services. This was particularly relevant in the case of local access to maternity care, as in the past two decades, British Columbia, like other jurisdictions in Canada and internationally, has seen an increasing centralization of maternity care in larger communities, ¹³ despite growing evidence on the maternity care needs of rural families and the desire for care as close to home as possible.^14,15 This is built on consolidated evidence regarding the health, psycho-social and cultural consequences of not providing this care.^13,16

Alongside the emergence of ‘networks’ as a solution to address decentralized care across or within regions, there has been growing evidence on enablers of network development,^17,18 including the role of mentorship and coaching,^17,19 the importance of clinical support from regional specialists, ¹⁸ and improved regional management of patients. ¹⁸ It has been well-established that trust is an essential precursor to the relationships that underscore a robust network infrastructure,^7,17 alongside contextual awareness of each practice site ²⁰ and opportunities to work together in-person. ²¹ Strategies to facilitate relationship development focus on mentorship and coaching ¹⁷ and emphasize the importance of clear communication ¹⁷ including virtual communication to mitigate geographical distances. ²¹

There is also growing evidence on the output of clinical network function, including reduced referrals to regional centres and improvements in the quality of referrals, ¹⁸ underscored by what Huxham and Vangen refer to as ‘collaborative advantage’ for issues that could not otherwise be addressed in silo. ^{22 (p.3)} Further benefits include resource leveraging, shared risk, increased efficiency, increased potential for innovation, capacity building and shared accountability, among other attributes. ²³ Regional networks which enhance connectivity between rural sites and regional referral centres have also been found to optimize the successful recruitment and retention of rural providers. ²⁴ Alongside evidence of network efficacy, however, are indications of known challenges to network development, namely developing trusting relationships, ²⁵ the potential for power imbalances across network sites ²⁶ and challenges of sustainability. ²⁷ Rural-specific literature cites further barriers including lack of understanding of rural context ²⁰ and limited inter-site access to information including difficulty in accessing patient data due to technological incompatibility between sites. ²¹

The emergence of RSON in British Columbia (BC) provides a valuable opportunity to assess the output of network function against the premise suggested in the growing body of evidence. We specifically focused on changes to regional relationships as these underscore the clinical capacity of small rural sites.

This qualitative study is part of a larger investigation into the efficacy of the RSON initiative. The larger study involved the quantitative analysis of health outcomes, qualitative analysis of process measures, and cost consequence analysis of the intervention to comprehensively determine value. From this broad dataset, regional relationships between specialists and local RSON providers emerged as a meaningful thematic category.

Settings and participants

Over the course of the RSON initiative, 169 participants contributed their voices to the evaluation of the RSON project. Initially, the RSON project included eight rural communities across BC, though three additional communities joined the program after the initial start date. Participation in the study was voluntary and open to all members of the hospital team. Participants included local community coordinators, Family Physicians both with and without Enhanced or Obstetrical Surgical Skills (FP-ESS or OSS), Family Practice Anesthetists (FPAs), registered nurses (RNs), health service administrators, medical device reprocessing technicians, operating room managers, midwives and booking clerks. Although we recognize the central role of team-based care in sustaining health services, this manuscript focuses on proceduralist physicians. Participating communities were chosen by Health Authority decision makers based on a need to stabilize local services and the perceived advantage the RSON interventions held for the community.

Data collection

Data was collected through 143 individual interviews and nine focus group interviews (2–3 participants each) over the length of the project (February 2019 to May 2022). A proportionate breakdown of participants’ professional designations is presented in Table 1. Participants could choose between an individual interview or a focus group interview, with both data collection methods occurring simultaneously. Interviews were conducted in person when possible or over Zoom videoconferencing software. Both were facilitated by the principal investigator (JK) in collaboration with a research assistant. Oral or written informed consent was received from all participants prior to the interviews. All participants granted permission for audio recording. Interviews lasted between 30 and 60 minutes, with most extending to 60 minutes. Although we observed data saturation before the end of the study, we continued to interview to ensure we captured nuances and changes over time and between communities. Recordings were transcribed by an external transcription agency and underwent a thorough process of anonymization as well as quality assurance to ensure accuracy. Interviews and focus group transcripts were then moved into aggregate data for analysis, as there was no discernable difference between data gained in each approach. The study was conducted in accordance with the guidelines and regulations of the University of British Columbia's Behavioural Research Ethics Board (Ethics #: H18-01940).

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Table 1.

Proportional breakdown of participants by professional designation.

Professional designation	Number of participants
Family physicians	39
Family physicians with enhanced surgical or obstetrical skills	14
Family practice anaesthetists	10
Hospital administrators	30
Nurse educators	4
Registered nurses	56
Registered midwives	12
Other	4
	Total: 169

Data analysis

Data analysis was guided by the methodological process of thematic analysis. ²⁸ Researchers achieved familiarization with the data through multiple readings of the interview transcripts, as well as listening to the audio recordings to ensure quality of the transcripts. Through immersion in the data, researchers identified regional relationships as a meaningful thematic topic. Once identified, two members of the research team inductively coded the relevant text using NVIVO 12 software, breaking down ideas and concepts observed in the data into further discrete categories, or ‘codes’ to create a codebook. Each researcher developed an independent coding framework, grouping-related codes together and nesting them into broader overarching categories. ²⁸ Following this step, the two codebooks were then compared; a high level of congruence was found between the two codebooks with only semantic differences between them. The merged codebook was then applied to the entire dataset.

Sub-themes related to ‘regional relationships’ were generated iteratively as the codebook was applied to the transcripts. Further steps included grouping, comparing and connecting how codes relate to others, and searching for overarching ideas and meaning within the dataset concerning regional relationships. The themes were developed directly from the data as opposed to being derived from an external theoretical framework.

Methodological rigour

Given the central role of researchers in generating themes and developing the analysis, researchers engaged in reflexivity, the process of critically reflecting on their own positionality and background so as to mitigate potential bias. Researchers were intentional in their ‘persistent observation’ of the data, repeatedly checking work against the dataset through the analysis to ensure accuracy of interpretations. In addition, researcher triangulation was used during codebook development in order to improve the credibility of the codebook and reduce over or under emphasis on any one theme. Each of these quality strategies was employed to improve the methodological rigour of the qualitative thematic analysis.

Improved relationships with regional referral centres

Participants identified clinical coaching as the primary mechanism through which they improved relationships with specialists in regional referral centres. This was due primarily to the reciprocal trust that was gained through increased access to clinical coaching opportunities and the consequent increased comfort in reaching out for clinical support.

Continued lack of engagement

Although most participants noted improved relationships through clinical coaching, a minority of participants reported experiencing continued resistance to FPESS/FPA practice in rural sites and the attendant lack of availability of referral specialists. Some felt this was rooted in urban-based perceptions of what Family Physicians do – and don’t do – including surgery. This resulted in situations where rural providers ‘[didn’t] feel all that welcome’ in referral centres. Many felt that this requires a ‘shift in Health Authority culture’ to overcome some of the ‘stigma’ that has existed historically. Other participants referred to the historical precedent of having patients travel to bigger centres for care (‘The mindset is still very much “we are the regional centre, this is where the majority of surgery happens”’ Family Physician 003). As one participant said, ‘You know, it's about that shift, you know we are players in the system. We can support the larger system, we are part of the team’ (Site Administrator 001). Some noted that the ‘stubborn pushback’ to this cultural shift has been frustrating, while others noted it will require educating referral specialists about the training of and need for rural FPESS (‘[W]ho else is going to do it, right?’ FP-ESS 004).

Several participants saw the root cause of the lack of acceptance resting in the need for regional procedural volume. Some were told by specialists that if they supported rural surgery, the regional program would ‘collapse’. Nevertheless, other participants noted that over time, concerns over volume scarcity have lessened in light of the recognition that regional referral centres could sustain their own programs alongside support of rural programs. Others pointedly observed that their relationship wasn’t strained, but instead there was ‘a little bit of a disconnect between how we see each other, and what our sort of hopes for the future are’ (Family Physician 003). This led to some participants advocating for a ‘careful, diplomatic approach’ in their relationships to facilitate change over time.

Regional coordination of patient care

A consequence of improved regional relationships for some RSON sites was increased participation of visiting specialists to expand the scope and volume of local procedural care. In some instances, this involved specialists opening satellite offices in the community, but a more common approach was regularly scheduled bi-weekly or monthly visits by specialists to work in the operating room and do follow-up post-operative care. Although this had occurred prior to the RSON initiative, many participants noted that the availability of additional funding for increased scope and volume facilitated both specialist involvement from diverse communities and enhanced procedural scope.

In many instances, specialist support for increased local care was reciprocated through rural physician assistance when health human resources were compromised in the referral centres: ‘We went to help them through a rough spot there. They didn't have any staff, and so we kept going’ (RN 002). Another participant noted,

We've had a couple times where we had patients who were supposed to be labouring or induced or something. [The referral centre] was so busy. They couldn't take them, so we took them. So, there's a little bit of that going on right now. (FP-ESS 004)

Despite the growing inter-site relationships, however, most participants noted the need for increased frequency of visits and an expanded local scope of care. Barriers to achieving this included geography: that is, the distance between sites and sometimes challenging travel conditions in rural British Columbia. As one participant noted,

[W]e’ve offered them OR space and tried to recruit people to come up and do outreach programs here. But I think the problem is that it's a long ways away for somebody to want to drive for three and a half hours to come up for an OR day. So I understand that [for] people with families it's a hard sell. I mean, we’re quite isolated here as, as you know, it's geographically a bit of a hard area. (FPA 005)

Other participants perceived that specialist availability was a bigger obstacle than distance. Although there was operating room availability in the rural site, participants recognized how much travel the specialists were already doing: ‘We could offer more. But they can’t travel more. They're really being stretched quite thin’ (FP-ESS 006).

Some participants identified challenges in the coordination of patient booking and referral processes as a barrier to specialist efficiency. Scheduling and balancing specialist slates became a complex task that often fell to over-stretched patient care coordinators at rural sites rather than being an established process at the regional service coordination level. This led to occasional underutilization of specialist time and acted as a barrier to specialist engagement.

For sites more proximal to their referral centres, challenges to increased specialist involvement were rooted more in limited physical and health human resource infrastructure in rural sites, specifically availability of equipment to facilitate surgeries. This was particularly salient for orthopaedic surgeries but extended to laparoscopic equipment as well. As RSON funding became available for sites to update equipment, this problem diminished. Participants reported that access to additional equipment became a significant enabler while challenges with distance and specialist capacity continued to be limiting factors.