In Canada, 16 million people or 50.6% of the Canadian population  live with a chronic disease . It has been acknowledged that managing these diseases is a complex process and that both the economic and social burdens are significant . For example, at the beginning of this millennium, the Public Health Agency of Canada estimated the direct and indirect costs of cardiovascular diseases at $18.5 billion a year , which is about 1.5% of the 2012 GDP . Patient numbers are growing rapidly due to the aging of the population and the greater longevity of people with chronic conditions . In addition, many studies have shown a major gap between usual and best practices in the screening, diagnosis, and treatment of chronic diseases . The challenge faced by practitioners and their organizations in developing and maintaining evidence-based practices is enormous.
Knowledge translation and interprofessional collaboration are two important components of continuous quality improvement of healthcare services. According to the Chronic Care Model [7, 8], services delivered to patients should be coordinated and based on the best available evidence. However, this requires a paradigm shift in the way we think about medical care: instead of focusing on the acute needs of individual patients, the Chronic Care Model calls for a thoughtful, organized, proactive approach to improving the healthcare of a patient population . A report issued by Quebec’s public health agency (the Institut national de santé publique du Québec, or INSPQ), based on consultation with experts and a literature review, described the main barriers to implementation of integrated primary healthcare in this province: lack of a clinical-practices information system that could be used to support clinical decision making, remuneration of healthcare professionals in a way that promotes ad hoc services rather than the actions required for chronic disease management, lack of organization and delivery of multidisciplinary services in primary care, and lack of an evaluation and feedback culture to facilitate the continuous quality improvement of these services .
The scientific literature continues to advocate interprofessional collaboration (IPC) as a key component of primary care. According to D'Amour and collaborators, collaboration is composed of two key elements: the construction of a collective action that addresses the complexity of client needs, and the construction of a team dynamic that integrates each professional’s perspective and in which team members respect and trust each other . Based on a recent Cochrane review, practice-based interventions aimed at increasing interprofessional collaboration through practice changes can improve healthcare and patient outcomes, and have generally proved to be less costly for front-line services . However, high-quality evidence from multi-method studies is still lacking. The College of Family Physicians of Canada (CFCP) has identified some important success factors for interdisciplinary collaboration in primary healthcare, the most important one being investing time in intra-group and inter-disciplinary communication . Processes such as team meetings and current practice audits may also influence interprofessional teamwork. Population and specific-patient needs’ assessments should be key determinants in deciding what kinds of teams are required and how to define interdisciplinary collaboration . The CFCP recommended that primary care groups be created and configured to meet the healthcare needs of the patient population, as defined by patient demographics and other data analyses related to the health of the population being served.
It further recommended that improvement of primary care services be supported by the delivery of feedback and performance measurements . Although providing feedback can be effective, its effects are generally small to moderate. In a recent systematic Cochrane review , the effect of using audits and feedback was found to vary widely across the included studies, and the quality of the evidence was moderate. The recommendations made following this extensive review were that feedback may be most effective when it reports greater gaps in health professionals’ performance, is provided more than once (both verbally and in writing), and includes targets and an action plan.
In 2008, the regional department of general medicine in Quebec’s Montérégie region (Département régional de médecine général, or DRMG) in collaboration with the Montérégie health and social services agency (Agence de la santé et des services sociaux de la Montérégie, or ASSSM) and the Quebec federation of general practitioners (Fédération des médecins omnipraticiens du Québec, or FMOQ), launched COMPAS, the collective for best practices and improvement in healthcare and services in family practice in Montérégie (Collectif pour des meilleures pratiques et l’amélioration des soins et services en médicine de famille). The objective of this ongoing project is to engage front-line healthcare professionals in a process of continuously improving the services they offer to persons suffering from chronic diseases in their territory. Interprofessional learning workshops are offered to physicians, nurses, pharmacists, and other professionals from the same region. In these workshops, information taken from clinical-administrative databases in the healthcare system are presented to the participants to provide them with feedback on the community of patients they are treating and on their practices, and to engage them in the process of working together to develop a collaborative quality-improvement project. Diabetes was identified by the project steering committee as the first priority target.
In 2010, researchers joined the COMPAS project team to support the development, implementation, and evaluation of this quality improvement strategy. Since continuing education workshops are a complex intervention composed of several interacting components [15, 16], the research team proposed that the project leaders begin by developing the theory underlying their interprofessional educational intervention. One of the main challenges involved in the innovative COMPAS approach is that of clearly identifying the intervention’s most important and measurable outcomes and also of explaining explicitly how it is intended to achieve change and the expected outcomes. As recommended by the UK Medical Research Council  with regard to the development and evaluation of complex interventions, a vitally important early task is to develop a theoretical understanding of the likely process of change by drawing on existing evidence and theory, supplemented if necessary by new primary research, such as interviews with those targeted by the intervention or involved in its development or delivery.
Aim of the study
The aim of our study was to describe the theory underlying the interprofessional educational intervention developed by the COMPAS project. The objectives were 1) to explain explicitly the set of assumptions held about the manner in which the program relates to its expected outcomes; 2) to describe the components of the complex intervention in detail; 3) to assess the intervention’s feasibility and acceptability, as well as possible improvements to it, and 4) to describe the intervention’s preliminary impacts. This paper will focus on the results obtained with respect to objectives one to three.