Gippsland Region Palliative Care Consortium (GRPCC) La Trobe University Palliative Care Unit (LTUPCU)

Transcription

1 Gippsland Region Palliative Care Consortium (GRPCC) La Trobe University Palliative Care Unit (LTUPCU) Developing capacity for palliative care in Gippsland: The role of the Gippsland Region Palliative Care Consortium: Capacity building in member organisations Wendy Dagher, Andrea Grindrod & Bruce Rumbold December 2014

2 Acknowledgements This project was funded by the Gippsland Region Palliative Care Consortium (GRPCC), in response to a proposal presented to the GRPCC Management Group in July We would like to thank all members of the GRPCC Management Group for their support, contributions and feedback relating to the project. We are particularly grateful to the Manager of the GRPCC, Vicki Doherty, who invited us to submit a proposal for the project in the first place. We are also indebted to the GRPCC Project Officer (After-hours Palliative Care Project, Research and Evaluation), Maria Garrett, who provided GRPCC documents, participant contact details and assistance with ethics applications and approvals. In addition we would like to express our appreciation to the participants of the project, who generously gave of their time to be interviewed for the project; their dedication to their work, knowledge of palliative care, reflections and insights have been vital to the project s success. Wendy Dagher Andrea Grindrod Bruce Rumbold FINAL Detailed Report - GRPCC organisational capacity.docx 2 of 99

3 Table of Contents Acknowledgements... 2 List of tables and figures... 6 Executive Summary... 7 Key findings... 7 Capacity Building... 8 Recommendations Continue and expand on existing programs and initiatives Improve GP engagement Community capacity building Relationship building and consultation with staff in member services Advocate for, and address needs of, local services... 9 Background Definitions Capacity building Organisational capacity building Aim Objectives Research questions Research design Method Interviews Participants Procedure for interviews Process for analysing interview data Themes of organisational capacity building Documents Description of types and sources of documents Document analysis procedure Validation strategy Results and discussion Research question 1: What impacts has the GRPCC had on the capacity of its member services to deliver palliative care? Relevant interview questions: Responses to interview questions: Relevant data from document analysis: Summary: FINAL Detailed Report - GRPCC organisational capacity.docx 3 of 99

4 Research question 2: Which initiatives of the GRPCC have had the greatest impact on the delivery of palliative care in the region? Relevant interview questions: Responses to interview questions: Relevant data from document analysis: Summary: Research question 3: What do staff of member services perceive as the key roles, or functions, of the GRPCC? Relevant interview questions: Responses to interview questions: Relevant data from document analysis: Summary: Research question 4: What does membership of the GRPCC provide to member services that they could not provide themselves? Relevant interview questions: Responses to interview questions: Summary: Research question 5: How would the delivery of palliative care in the Gippsland region be affected if the GRPCC ceased to exist? Relevant interview questions: Responses to interview questions: Summary: Challenges Relevant interview questions: Responses to interview questions: Impacts of GRPCC in areas other than palliative care Relevant interview questions: Responses to interview questions: Suggestions for improvement/future directions Relevant interview questions: Responses to interview questions: Conclusion Recommendations Continue and expand on existing programs and initiatives Improve GP engagement Community capacity building Relationship building and consultation with staff in member services Advocate for, and address, needs of local services Appendices FINAL Detailed Report - GRPCC organisational capacity.docx 4 of 99

5 Appendix 1 Participant Information Statement Appendix 2: Interview schedule Appendix 3: List of initiatives of the GRPCC since Appendix 4: Initial framework for assessing organisational capacity in GRPCC member services, based on Crisp et al. (2000), including pre-determined themes and their definitions Appendix 5: Final themes, definitions, and related GRPCC strategic directions and initiatives Appendix 6: Table of evidence from document analysis organised by organisational capacity building themes Appendix 7: Evidence from interview questions to answer research question 1, organised by organisational capacity building themes Appendix 8: Table of initiatives perceived to have had the most significant impact on improving palliative care across the region Appendix 9: Participants perceptions of the key roles or functions of the GRPCC Appendix 10: Evidence from interview questions to answer research question 4, organised by themes Appendix 11 Evidence from interview questions to answer research question 5, organised by themes: expected impact on palliative care service delivery if GRPCC ceased to exist Appendix 12 Anticipated types of changes to palliative care if no one fulfilled roles of GRPCC Appendix 13 Challenges regarding participation in the GRPCC Appendix 14 Impacts of GRPCC in areas other than palliative care Appendix 15 Suggestions and future directions for the GRPCC FINAL Detailed Report - GRPCC organisational capacity.docx 5 of 99

6 List of tables and figures Table 1 Final framework for assessing organisational capacity in GRPCC member services, based on Crisp et al. (2000), including pre-determined themes, re-developed themes and their definitions Table 2 Summary of evidence from interview questions to answer research question 1, organised by organisational capacity building themes Table 3 Comparison of evidence from documents and interviews regarding impacts of GRPCC on organisational capacity of member services Figure 1 GRPCC initiatives with most significant impact across Gippsland (% of responses); n= Table 4 Participants' perceptions of the key roles or functions of the GRPCC Table 5 Evidence from interview questions to answer research question 4, organised by themes Table 6 Evidence from interview questions to answer research question 5, organised by themes: expected impact on palliative care service delivery in services and across the region if GRPCC ceased to exist Table 7 Anticipated types of changes to palliative care if no one fulfilled roles of GRPCC Table 8 Challenges regarding participation in the GRPCC Table 9 Impacts of GRPCC in areas other than palliative care Table 10 Suggestions and future directions for the GRPCC FINAL Detailed Report - GRPCC organisational capacity.docx 6 of 99

7 Executive Summary The aim of this project was to investigate the influence of the GRPCC on the capacity of member services to deliver palliative care in the Gippsland region since the introduction of Victoria s Strengthening palliative care: Policy and strategic directions Of particular interest was: The impact of member organisations' involvement in the GRPCC on their organisational capacity to deliver palliative care services. The perceived value of the GRPCC to staff of member services. The effectiveness of GRPCC as a means for improving the provision of palliative care services in the region. To investigate this, we asked these questions of 31 people working at one of the 14 GRPCC member services or as a member of the GRPCC team: 1. What impacts has the GRPCC had on the capacity of its member services to deliver palliative care? 2. Which initiatives of the GRPCC have had the greatest impact on the delivery of palliative care in the region? 3. What do staff of member services perceive as the key roles, or functions, of the GRPCC? 4. What does membership of the GRPCC provide to member services that they could not provide themselves? 5. How would the delivery of palliative care in the Gippsland region be affected if the GRPCC ceased to exist? All GRPCC member services were represented amongst the participants. In this report the primary focus is on their responses, as the GRPCC Management Group has emphasised the importance of obtaining the views of staff at the coal face. We have also filled in the background by consulting a range of documents produced over the last four years by the consortium. These two sources of information shape our comments and recommendations. Key findings In response to each of the questions, our findings are: 1. The GRPCC has had a positive impact on the organisational capacity of its member services to deliver palliative care in Gippsland. This is affirmed in both interviews and GRPCC publications. Some challenges have also been identified, and these are outlined below. 2. The GRPCC initiatives with greatest impact on member services capacity to deliver high quality palliative care to their patients are the Visiting Palliative Care Specialist Program, the Nurse Practitioner/Candidate Program, the education/training program, and the clinical tools and guidelines. 3. All participants had a clear understanding of some key roles or functions of the GRPCC. Almost all identified GRPCC s management of the service delivery framework as a key contribution, and all mentioned advantages of belonging to the GRPCC, especially in the provision of resources, education/training and policy development. All other roles identified in GRPCC documentation were mentioned by at least some participants, but no single participant described the full extent of GRPCC s brief. A few additional roles not mentioned in GRPCC documentation were however identified. Not surprisingly, it seems that member services see the GRPCC principally in terms of its contribution to their service, albeit with some awareness of the broader scope of the consortium s activities and responsibilities. 4. Almost all participants perceived the GRPCC as highly valuable to its member services, affirming it as an effective means of improving the standard of palliative care services across the region. For some services, particularly those linked with agencies providing a range of healthcare services, the GRPCC adds value not only to their palliative care practice but also to other aspects of their operations. For other, smaller, services the GRPCC is essential to their continuing operation, providing resources they would not otherwise be able to generate for themselves. 5. It is clear that member services depend on the GRPCC to support them in delivering high quality palliative care, especially through resource allocation, policy development and education. Most respondents believed that their palliative care service delivery would be negatively impacted if the GRPCC ceased to exist. Even though a few services, with relatively high levels of palliative care expertise, felt they would not feel the FINAL Detailed Report - GRPCC organisational capacity.docx 7 of 99

8 absence of the GRPCC, they expressed considerable concern for their colleagues across the region for whom the GRPCC is crucial to their role of providing good palliative care services. The most common challenges identified related to services having insufficient resources to implement GRPCC initiatives, and some difficulties in ensuring the right people in services received the right information from the GRPCC. Some commented that GRPCC activities were not necessarily relevant to the needs of each local service; and a lack of funding for palliative care was identified. Participants also reported impacts in their services not related to palliative care, such as the adaptation of ideas from a GRPCC program to be used in another area of health care, and use of skills and knowledge learnt through the GRPCC education program in areas other than palliative care. Ideas for future directions to be taken by the GRPCC included continuing or expanding on existing programs and initiatives, focusing on engaging GPs, building greater community capacity for palliative care, building stronger relationships between GRPCC and staff in local services, ensuring that their initiatives meet the differing needs of local services, and collaboratively advocating for the palliative care needs of the region. Capacity Building In the body of this report we have organised the interview and document data using a comprehensive model of capacity building. This model identifies both strengths and weaknesses in the organisational capacity building being undertaken by GRPCC. We cannot however comment on whether any or all of these weaknesses should be addressed by GRPCC. In some instances the GRPCC itself lacks the capacity to address the issue: the fact that the consortium does not control funding to services is a case in point. Nevertheless, we offer this analysis to the GRPCC, hoping that it may assist both consortium and member services in clarifying the scope of the consortium s contribution. There is some evidence that not all involved in palliative care provision in Gippsland understand all aspects of what the consortium does, or does not, contribute. It is also important to note that not all the areas of organisational capacity building themes would be able to be realistically addressed by the GRPCC, since some of the themes are beyond its sphere of governance. The fact that the GRPCC has made positive impacts across many domains of organisational capacity building, indicates that these achievement are very significant. The GRPCC has placed a high priority on supporting its member services to build capacity in clinical service delivery. This is not surprising given that, compared with metropolitan health services, rural services have a relatively lower level of access to, and availability of, resources needed to deliver essential health care to their communities. The recommendations that follow are based on findings of the interviews, but influenced by both the supporting document and capacity building analyses. Some recommendations inevitably have an aspirational nature. We have interpreted our task as being to identify possibilities: the consortium, with the local knowledge we lack, can then decide which of these are viable options. Recommendations 1. Continue and expand on existing programs and initiatives The GRPCC should continue to support the Specialist Palliative Care Consultancy Service, NPC Program, education/training program, aged care link nurse program, raising standards of care, volunteer training and recruitment, after-hours project, and carers. Particular attention should be given to: Ensuring that all services in all sub-regions have adequate access to the Palliative Care Specialist. Providing more online education/training and expanded access via videoconferencing, thus enabling greater access for staff in remote areas. FINAL Detailed Report - GRPCC organisational capacity.docx 8 of 99

9 Streamlining data collection and reporting requirements for services, and providing related education and support. 2. Improve GP engagement Some local services need the GRPCC to play a greater role in engaging GPs with their programs. This could include: Surveying GPs about their knowledge and needs in the area of palliative care, perhaps in consultation with GML. Developing a model for GP education that caters specifically to the needs of GPs and involves relevant palliative care specialists. Asking member services which have had success in engaging GPs for advice to assist other services that are experiencing difficulties in this regard. 3. Community capacity building Community capacity building for palliative care was identified as an important area for further development in Gippsland (Strategic Direction 7: Ensuring support from communities). We recommend that the GRPCC consider: Investigating existing community based initiatives in Gippsland relating to palliative care to both map and improve understanding of community generated activities in the region. Funding and/or supporting other community capacity building projects such as the Gippsland Lakes Community Health project, and evaluating their effectiveness to improve individual and collective community resilience on end of life issues. Expanding its efforts in promotion and community education about palliative care and end-of-life issues, including publicising community capacity building projects and activities through a number of channels, such as the media, health services, community organisations, and academic publications. 4. Relationship building and consultation with staff in member services The GRPCC should increase its focus on building relationships with staff in services, in particular providing opportunities for staff to give feedback about GRPCC initiatives. In doing so the GRPCC might consider: Identifying and supporting potential palliative care champions in each service and focus on building strong relationships with them. Ensuring that there are clear communication processes between themselves and services, and that the correct information is relayed to the appropriate staff members. 5. Advocate for, and address needs of, local services To ensure that their initiatives meet the differing needs of local services, the GRPCC should: Coordinate a collective approach for advocacy to Government for regional needs in palliative care, in close consultation with its member services. Assist services to overcome the challenge of balancing daily demands with implementing new initiatives, by streamlining and integrating initiatives. Consider conducting, in collaboration with each service, an assessment of each service s current organisational capacity building activities, to identify areas of strength and areas for development. Recognise when services already have efficient, high quality models that work for them. Consult with services to help them tailor initiatives/projects to suit the needs of their service and/or sub-region. Consider ideas about different funding models that may allow services to use funds for purposes that suit their local needs. Ensure that unfunded services receive support equivalent to that of funded services, since all are providing palliative care. FINAL Detailed Report - GRPCC organisational capacity.docx 9 of 99

10 This report relates to the first phase of the project, which primarily focused on organisational capacity building of GRPCC member organisations. Phase 2 of the project, scheduled to commence in 2015 will predominantly focus on community capacity building in the Gippsland Region. FINAL Detailed Report - GRPCC organisational capacity.docx 10 of 99

11 Research Report Background In 2004, the Victorian Government's palliative care policy led to the establishment of the GRPCC and seven other regional consortia. The work of the consortia and palliative care services is guided by the Strategic Directions outlined in Victoria s Strengthening palliative care: Policy and strategic directions The consortia have provided leadership in the promotion and delivery of high quality palliative care services throughout their respective regions. The GRPCC has undertaken regional planning and coordination of service provision, and has worked in partnership with the Palliative Care Clinical Network (PCCN) to manage the service delivery framework, communication, capacity building and initiatives for improving clinical services in the Gippsland region. The GRPCC Manager commissioned this project to examine the contribution of the GRPCC to increasing the capacity of its member organisations (including both voting and non-voting members) to provide palliative care services to the Gippsland community. The GRPCC has overseen the implementation of many initiatives, and has evaluated their effectiveness. These specific evaluations have informed the continuous improvement of various aspects of palliative care in the region. However, an independent study of the broader impacts on member organisations capacity to deliver palliative care services had not been undertaken. Furthermore, an overarching evaluation was expected to assist in determining the value of the GRPCC in facilitating improvements in end-of-life care in Gippsland. This research report describes Phase 1 of a two phase research study. The two phase study will examine the impact of the GRPCC on organisational and community capacity with regard to palliative care in the Gippsland region. Phase 1 has focused on organisational capacity, whereas Phase 2 will focus on community capacity. Definitions Capacity building Capacity building refers to building on existing strengths in an individual, organisation, community or system; this involves increasing involvement, decision-making and ownership of issues (VicHealth, 2012). The aim of capacity building interventions is to change an organisation s or community s ability to address health issues in a sustainable manner, through creating new structures, approaches and/or values (i.e. systemic change) (Crisp, Swerissen, & Duckett, 2000). Organisational capacity building Organisational capacity building is focused on sustainable workforce development (VicHealth, 2012), changing organisational structures, allocating resources, and making a commitment to health improvement (Hawe, Noort, King, & Jordens, 1997). The central elements of organisational capacity are development of staff skills and knowledge, and access to resources, which lead to sustainable, improved health care for clients and communities (Hanusaik et al., 2007). This project has focused primarily on organisational capacity building; this has been assessed by examining the impact of the GRPCC on building capacity for palliative care in its member services. FINAL Detailed Report - GRPCC organisational capacity.docx 11 of 99

12 Aim The main aim of this project was to investigate the influence of the GRPCC on the capacity of member services to deliver palliative care in the Gippsland region, since the advent of Victoria s Strengthening palliative care: Policy and strategic directions Objectives 1) To determine the impact of member organisations' involvement in the GRPCC on their organisational capacity to deliver palliative care services. 2) To ascertain the perceived value of the GRPCC, according to staff of member services. 3) To establish whether or not the GRPCC is an effective means for improving the provision of palliative care services in the region. Research questions 1. What impacts has the GRPCC had on the capacity of its member services to deliver palliative care? 2. Which initiatives of the GRPCC have had the greatest impact on the delivery of palliative care in the region? 3. What do staff of member services perceive as the key roles, or functions, of the GRPCC? 4. What does membership of the GRPCC provide to member services that they could not provide themselves? 5. How would the delivery of palliative care in the Gippsland region be affected if the GRPCC ceased to exist? Research design This project used a qualitative research design. To adequately answer the research questions, the research team inquired into the experiences and opinions of staff who work at the various member organisations. The research team considered the detailed and complex views and descriptions provided by the participants, to identify and understand the range of important issues raised, and to obtain a rich description of the impact and value of the GRPCC s work. These descriptions were integrated with data gleaned from organisational documentation. FINAL Detailed Report - GRPCC organisational capacity.docx 12 of 99

13 Method Data was collected via semi-structured interviews and document analysis. The interviews were the primary source of data because the researchers wanted to focus on the views and voices of people working in the services. The importance of obtaining the views of staff at the coal face was strongly emphasised by the GRPCC Management Group. The document analysis provided background information for the researchers, and served as a means of validating the interview data. Ethical approval for the project was obtained from the Latrobe Regional Hospital Human Research Ethics Committee (ethics approval number LNR) and the La Trobe University Faculty of Health Sciences Faculty Human Research Ethics Committee (ethics approval number FHEC14/142). Interviews Participants There were 31 participants interviewed for this research project. Participants worked at one of the 14 GRPCC member services, or as a member of the GRPCC team. The potential participants were selected on the basis of their involvement with, and knowledge of, palliative care; participants included Coordinators of Palliative Care, Nurse Practitioner candidates, GRPCC Management Group representatives, and the Nurse Practitioner Mentor. At least one participant was interviewed from each member service. Of the 38 potential participants invited to take part in the study, 7 were unavailable for interview. Member services include both acute and community health care organisations, some of which are specialist palliative care services, located in Gippsland, Victoria, Australia. There are 9 voting member services: Bairnsdale Regional Health Service (BRHS) Bass Coast Health (BCH) formed in July 2014, through the integration of Bass Coast Community Health Service and Bass Coast Regional Health Central Gippsland Health Service (CGHS) Gippsland Lakes Community Health (GLCH) Gippsland Southern Health Service (GSHS) Latrobe Community Health Service (LCHS) Latrobe Regional Hospital (LRH) West Gippsland Healthcare Group (WGHG) Yarram and District Health Service (YDHS) There are 5 non-voting member services: Gippsland Medicare Local (GML) Kooweerup Regional Health Service (KRHS) Omeo District Health (ODH) Orbost Regional Health (ORH) South Gippsland Hospital (SGH) Procedure for interviews Potential participants were invited by the research team to take part in the study. Initial contact was made via , with the Participant Information Statement attached (refer to Appendix 1). The research team phoned potential FINAL Detailed Report - GRPCC organisational capacity.docx 13 of 99

14 participant a few days later to answer any questions about the research and to arrange a suitable interview time. Written Consent was obtained from each participant prior to conducting the interview. Each participant took part in one semi-structured telephone interview of approximately minutes duration (refer to Appendix 2 for the interview schedule). The researcher made handwritten notes during the interview to record the participant s responses. The interview notes were later typed up in Microsoft Word, then imported into NVivo (qualitative analysis software) for analysis. Personal details of all participants have been kept confidential. All data has been de-identified in any presentation or report produced as a result of this research project. Consent forms, interview cover sheets, and interview recording sheets were all stored separately and securely in a locked filing cabinet in the Department of Public Health and Human Biosciences at La Trobe University. Process for analysing interview data Using NVivo, the researchers used a series of coding processes to analyse the interview data. The first stage of coding involved matching data from particular interview questions to the relevant research question. For example, research question number 2, which initiatives of the GRPCC have had the greatest impact on the delivery of palliative care in the region?, was addressed by analysing the responses to the following interview questions: Which initiative of the GRPCC has had a significant impact in the region? Why has this been significant? Are there any other initiatives that stand out due to their impact in the region? Why?. The second stage of coding for themes of organisational capacity building is described below. Themes of organisational capacity building The second stage of coding was used to organize interview data into themes of organisational capacity building. A framework was developed from the academic literature and government guidelines for assessing organisational capacity building (refer to Appendix 5). Government documents included the Victorian Health Promotion Foundation s Capacity building for health promotion information sheet (2012) and the NSW Department of Health s Framework for building capacity to improve health (2001). The following research databases were searched: Medline, Cinahl and Informit Health. Key search terms used singularly and in combination were: capacity building, capacity measurement, healthcare, health services, palliative care, terminal care, end-of-life care, rural health, organisational/organisational, and health care delivery. According to the academic literature, a consensus has not been reached regarding the establishment of a framework or model for measuring or assessing organisational capacity of health services to deliver palliative care. However, Crisp et al. (2000) have developed a comprehensive framework which identifies four approaches to organisational capacity building; the categories described within each approach seem to cover most domains of capacity building identified in the literature as being important for building organisational capacity in health care. These categories were used as the initial pre-determined themes for this research project (refer to Appendix 4). The set of organisational capacity building themes adopted for this project are defined below in Table 1. Other sets of thematic coding were developed to analyse data related to particular research questions. These themes are discussed in the relevant parts of the Results and Discussion section. FINAL Detailed Report - GRPCC organisational capacity.docx 14 of 99

15 Table 1 Final framework for assessing organisational capacity in GRPCC member services, based on Crisp et al. (2000), including pre-determined themes, re-developed themes and their definitions Approach to capacity building (Crisp et al., 2000) Theme/domain Definition Top down Organisational implementation Changes in organisational structure, leadership, and decision making processes to facilitate capacity building. Includes region-wide vision/perspective, prioritising palliative care, and raising the profile of palliative care. Bottom up Policy development Resource allocation Sanctions/incentives for compliance Ideas generated & implemented Workforce/ skills/ PD program (incorporates Staff skills, understanding, participation & commitment) Development of policies, guidelines and tools for staff to use in their delivery of services. Includes consistency of care. Provision of resources (human, financial, information technology, information, specialist advice) to assist staff in their work. Includes support to services and communication with services. Mechanisms for performance management and quality assurance, relevant to the area of capacity building. Staff encouraged to generate ideas and given opportunity to implement them. Training and education opportunities available to staff, to enable them to build on existing knowledge and skills. Opportunities for staff to utilize new skills and knowledge, engage in reflective practice (including attitudes and values) about their work, and to share their knowledge with colleagues. Partnerships Community activation Efforts to form partnerships with community members/organisations (including volunteering). Collaborations, networking and information sharing (incorporates Network density) Individual organisation reorienting of services & programs Collaborative partnerships and development of networks across organisations, and between different groups (i.e., groups with different levels of influence or from different professions). Building the number and depth of relationships between staff, both within and between organisations. Changes in the way an organisation delivers its services and programs. Community organizing Community ownership Opportunities for community members to initiate, contribute and take responsibility for developing capacity. Involvement of key community leaders Involvement of persons from disadvantaged groups Opportunities for key community leaders to become involved in community capacity building. Opportunities for members of disadvantaged groups to be involved in capacity building, through access to information, education and support. FINAL Detailed Report - GRPCC organisational capacity.docx 15 of 99

16 Documents Document analysis was used as the secondary method of data collection and analysis. This method was used to obtain background information and context for the research project, and as a means for data triangulation (verifying data collected during interviews). The documents also provided a form of verification that the GRPCC have taken actions to follow their strategic directions; and that the strategic directions aligned with strategies, processes, projects, or activities for increasing organisational capacity of member services; and that these initiatives were consistent with approaches to organisational capacity building identified in the academic literature. Description of types and sources of documents Documents were obtained from the GRPCC website ( and from the GRPCC project team. There were 78 documents that related to GRPCC activities occurring from 2011 to 2015 (documents created before November 2014). Types of documents included: brochures, web pages, newsletters, annual reports, strategic plan, meeting minutes and agendas, project proposals, evaluation reports, and GRPCC staff presentations. Document analysis procedure The three step document analysis process described by Bowen (2009) was adapted for use in the current project: 1. Skimming (superficial examination to select pertinent data) a. Eliminated all documents relating to GRPCC prior to remaining documents were scanned for data relevant to the predetermined themes; none of these documents were discarded. b. Initial read/skim through all remaining documents to see which ones appeared to be relevant to particular themes created list in excel table which included aspects of relevance. In determining the relevance of documents, the following factors were considered: document s meaning and how it contributed to addressing the research questions; document s authenticity, credibility, accuracy and representativeness; and the document s original purpose and target audience. 2. Reading (thorough examination of the selected data by re-reading) a. Went through one document at a time, carefully re-reading the document to identify text relating to themes ; made note of themes in excel table. b. Some documents were grouped together for analysis, due to the similarity in their content and associated themes (e.g., Newsletters; CPG meeting minutes; ORG meeting minutes). 3. Interpretation (developing/revising themes to make sense of the selected data) a. Re-developed themes from the data under each initial theme (some themes may be combined, or new themes created, through the process of making sense of the data) b. Key themes were identified (10 out of the 14 original themes were retained; the remaining 4 themes were reconstructed due to significant overlap of data coded under each of these individual themes, resulting in 2 new themes); the final hierarchy of the 12 themes used in the data analysis is provided in Table 1. Validation strategy To maximise the validity of the findings, data were triangulated. As already outlined, data were obtained from multiple sources, both within and between the member services. Collecting data from a variety of sources, a range of informants, and in different forms, has enabled the data to be compared and contrasted to obtain a thorough understanding of the topic of inquiry. Data obtained from both methods of analysis have been compared and integrated, to provide a detailed picture of the impact of the GRPCC on capacity building in its member organisations. The validation strategy has been employed in response to each of the research questions (see Results and Discussion section). FINAL Detailed Report - GRPCC organisational capacity.docx 16 of 99

17 Results and discussion Research question 1: What impacts has the GRPCC had on the capacity of its member services to deliver palliative care? The aim of this research question was to find out how the GRPCC has contributed to organisational capacity building in its member services. Both interview data and documents were analysed. Relevant interview questions: In what ways has the GRPCC impacted on your organisations capacity to deliver palliative care services? Can you give any examples of this, in the day to day work of your organisation? Responses to interview questions: Out of 31 participants, 30 responded to the interview questions relating to research question 1. Participants responses provided evidence for ten out of the twelve themes of organisational capacity building. As summarised in Table 2, there was considerable evidence for the themes of: Resource allocation; and Workforce/skills/PD program (refer to Appendix 7 for the full tabulation of results). There was moderate evidence for the themes of: Organisational implementation; and Policy development. Limited evidence was found for the themes of: Sanctions/incentives for compliance; Ideas generated & implemented; Community activation; Collaborations, networking & information sharing; Individual organisation reorienting of services & programs; and Involvement of people from disadvantaged groups. There was no evidence of Community ownership, nor of Involvement of key community leaders. It should also be noted at this point that this lack of response may reflect participants focus on service delivery rather than the community engagement that does exist: although we might expect to pick up relevant references in the various services literature. Nor is it necessarily appropriate to expect GRPCC to deliver on all aspects of capacity building: sanctions/incentives, for example, assume the capacity to control activities through allocation of funding. GRPCC however operates by encouragement and persuasion, not by compulsion. The majority of respondents (87%) reported that the work of the GRPCC has impacted positively on member services, by increasing their capacity to deliver palliative care. However, 4 out of 30 respondents indicated that their service s capacity to provide palliative care has not improved as a result of the efforts of the GRPCC, reasoning that these services were already working at their maximum capacity or were already operating a good quality palliative care program. Even though services were receiving more referrals, which they attributed to the greater awareness of palliative care services across the region, they were not able to meet the demand. FINAL Detailed Report - GRPCC organisational capacity.docx 17 of 99

18 Table 2 Summary of evidence from interview questions to answer research question 1, organised by organisational capacity building themes Theme (domain of organisational capacity building) Quality & extent of evidence from interview data Considerable (>=66% of respondents); moderate (34-65% of respondents); limited (1-33% of respondents); no (0% of respondents). 30 respondents TOP DOWN Organisational implementation MODERATE: 18 (60%) Policy development MODERATE: 19 (63%) Resource allocation CONSIDERABLE: 26 (87%) Sanctions/incentives for compliance LIMITED: 4 (13%) BOTTOM UP Ideas generated & implemented LIMITED: 3 (10%) Workforce/skills/PD program CONSIDERABLE: 24 (80%); PARTNERSHIPS Community activation LIMITED: 4 (13%) Collaborations, networking & information sharing LIMITED: 11 (37%) Individual organisation reorienting of services & programs LIMITED: 1 (3%) Community ownership NO: 0 Involvement of key community leaders NO: 0 COMMUNITY ORGANISING Involvement of people from disadvantaged groups LIMITED: 1 (3%) NO IMPACT ON ORGANISATIONAL CAPACITY BUILDING No impact LIMITED: 4 (13%) N.B. # FINAL Detailed Report - GRPCC organisational capacity.docx 18 of 99

19 Relevant data from document analysis: The document analysis indicated that the GRPCC has made an impact on a range of areas of organisational capacity building in its member services. There was considerable evidence from the documents of a variety of strategies, activities and processes that demonstrate a number of themes of organisational capacity building: Organisational implementation; Policy development; Resource allocation; Sanctions/incentives for compliance; Workforce/skills/PD program; Collaborations, networking & information sharing; and Involvement of people from disadvantaged groups (refer to Table 3). There was moderate evidence for Community activation, but only limited evidence for Ideas generated & implemented; Individual organisation reorienting of services & programs; Community ownership; and Involvement of key community leaders. Thus there is some disparity between the perceptions of the staff members interviewed and the documents of the consortium. FINAL Detailed Report - GRPCC organisational capacity.docx 19 of 99

20 Table 3 Comparison of evidence from documents and interviews regarding impacts of GRPCC on organisational capacity of member services Theme (domain of organisational capacity building) Quality & extent of evidence from interview data (Appendix 7) Quality & extent of evidence from document analysis (Appendix 6) Comparison of evidence between interview & document analysis (considerable, moderate, limited, no) (considerable, moderate, limited, no) Organisational implementation Top down MODERATE: 18 (60%) CONSIDERABLE DIFFERENT Policy development MODERATE: 19 (63%) CONSIDERABLE DIFFERENT Resource allocation CONSIDERABLE: 26 (87%) CONSIDERABLE CONSISTENT Sanctions/incentives for compliance Ideas generated & implemented Workforce/skills/PD program Community activation Collaborations, networking & information sharing Individual organisation reorienting of services & programs Community ownership Involvement of key community leaders Involvement of people from disadvantaged groups LIMITED: 4 (13%) CONSIDERABLE DIFFERENT Bottom up LIMITED: 3 (10%) LIMITED CONSISTENT CONSIDERABLE: 24 (80%) CONSIDERABLE CONSISTENT Partnerships LIMITED: 4 (13%) MODERATE DIFFERENT LIMITED: 11 (37%) CONSIDERABLE DIFFERENT LIMITED: 1 (3%) LIMITED CONSISTENT Community organising NO: 0 LIMITED DIFFERENT NO: 0 LIMITED DIFFERENT LIMITED: 1 (3%) CONSIDERABLE DIFFERENT No impact on organisational capacity building No impact LIMITED: 4 (13%) N/A N/A FINAL Detailed Report - GRPCC organisational capacity.docx 20 of 99

21 Summary: Taken together, the findings from the document analysis and analysis of interview data indicate that the GRPCC has made significant contributions to building organisational capacity in its member services to improve the delivery of palliative care across Gippsland. Areas of particular strength were policy development, resource allocation, workforce/skills/pd program, and organisational implementation. However, there were some disparate findings between the interview data and documents. The document analysis shows that the GRPCC has undertaken considerable work in the areas of sanctions/incentives for compliance; collaborations, networking and information sharing, and involvement of people from disadvantaged groups. In contrast, the interviews barely mentioned these initiatives. Such discrepancies could arise because staff members in services are unaware of some of the work being carried out by the GRPCC, so did not mention these areas when interviewed. Or it could be that the policies, ideas and documentation have been well developed, but the outcomes and impacts in services have not yet become apparent. Areas for improvement include ideas generated and implemented, individual organisation reorienting of services and programs, community ownership, and involvement of key community leaders. These findings demonstrate that there is scope for the GRPCC to encourage greater contribution and feedback from staff in services about their ideas for improving palliative care and putting into practice the initiatives of the GRPCC. There is also opportunity for the GRPCC to work with services to reorient and adapt the initiatives to suit local needs. FINAL Detailed Report - GRPCC organisational capacity.docx 21 of 99

22 Research question 2: Which initiatives of the GRPCC have had the greatest impact on the delivery of palliative care in the region? The aim of this research question was to determine which initiatives of the GRPCC have had the greatest impact on palliative care delivery in Gippsland, according to staff of member services. Both interview data and documents were analysed. Relevant interview questions: Which initiative of the GRPCC has had a significant impact in the region? Why has this been significant? Are there any other initiatives that stand out due to their impact in the region? Why? Responses to interview questions: All 31 participants responded to each of the interview questions relating to research question 2, with a total of 75 responses (some participants gave more than one response). Participants responses indicated nine initiatives as having a significant impact on the provision of palliative care in the region (refer to Figure 1 for summary data, and Appendix 8 for the full tabulation of results). The Visiting Palliative Care Specialist Program was the initiative perceived to have the greatest impact on improving palliative care in the region, making up nearly one third of responses (29%). Access to Specialists has improved staff knowledge and has assisted in building relationships with local GPs, as well as enhancing GPs knowledge of palliative care. Specialist advice and consultation (primary and secondary) has helped staff engage in best practice and therefore increase the standard of care for all patients, including those requiring complex symptom management. The Nurse Practitioner/Candidate Program was also perceived as having a major impact on the improvement of palliative care delivery in the region, comprising 20% of responses. Staff in services have appreciated having face-toface access to NPCs, who are perceived as local palliative care experts. NPCs have often been available for advice and support, when it has not been possible to contact a GP or Visiting Specialist. NPCs have also facilitated communication and relationships with GPs and Specialists, which has increased the capacity of services to deliver a higher standard of palliative care to their patients, both in the community and in acute settings. Another initiative perceived to have significant impact across Gippsland was the education/training program, which comprised 20% of responses. Staff in services report increased knowledge and skill development as a result of high quality education/training opportunities. Staff in remote locations have appreciated being able to access education without having to travel to Melbourne. The confidence and competence of staff in services, particularly generalist nurses, has grown as a result of attending education/training, leading to greater capacity in the palliative care workforce. Finally, the development and implementation of evidence based clinical tools and guidelines have reportedly contributed to significantly improving palliative care services across the region (20% of responses). Consequently, services have provided more consistent and higher quality care. FINAL Detailed Report - GRPCC organisational capacity.docx 22 of 99

23 Volunteer training, 3 Palliative aged care resource/link nurse, 8 Resources/informatio n for staff & patients, 5 Psychosocial/bereave ment support, 1 Visiting palliative care specialist program, 29 After hours model, 7 Clinical tools & guidelines, 20 Nurse Practitioner Candidate Program, 20 Education/training program, 20 Figure 1 GRPCC initiatives with most significant impact across Gippsland (% of responses); n=75 While the majority of respondents were very satisfied with the initiatives implemented by the GRPCC, a couple of challenges were identified. One respondent commented that there was some lack of clarity around the differences in what could be provided by a NP/C compared with a Clinical Nurse Consultant; there was some hesitation related to the value of the NP/C program in that particular service, but also recognition that the NP/C program was of immense value across Gippsland. Another area of concern related to the use of Clinical tools and guidelines; the respondent indicated that the tools were potentially very useful, but she was uncertain as to how consistently the tools were being used in services. There were a few initiatives not mentioned during the interviews, namely: improved access to respite; strengthening links between the GRPCC and stakeholders; and health promotion of palliative care. Possible reasons could be due to a lack of awareness or promotion of these initiatives as emanating from the GRPCC. Another explanation could be that the effects of these initiatives are either not yet evident in services or their communities, or perhaps have not been valued by staff of member services. Alternatively, these initiatives may not have been as effective as anticipated. No doubt, opinions of patients, carers, and other community members would shed some light on these possibilities. FINAL Detailed Report - GRPCC organisational capacity.docx 23 of 99