Abstract
Problem addressed Family physicians stand to benefit from assistance with the implementation of social accountability strategies.
Objective of program To develop rapid evidence narratives for key social accountability topics that summarize and mobilize evidence for practical use in social accountability strategies linking front-line, “bottom-up” actions with complementary “top-down” standards from the SAFE (Social Accountability as the Framework for Engagement) for Health Institutions evaluation tool.
Program description The SAFE for Health Institutions project aims to accelerate transformation toward greater social accountability in family medicine practices and in other settings where family physicians work. A social accountability evaluation tool was developed to help with this transformation and includes a framework of 253 comprehensive top-down standards. Key social accountability topics linked to these standards were identified for rapid reviews of the literature, conducted between June and November 2021, with evidence reported as narratives. These rapid evidence narratives provide practical, evidence-based context including suggestions on how to address each topic across the micro, meso, and macro levels of care, connecting bottom-up actions with corresponding considerations for top-down policies, processes, and structures. Summaries of the rapid evidence narratives are being developed as a series of articles for Canadian Family Physician, focusing on what family physicians can do in clinical practices, with interdisciplinary teams, and in other work settings to accelerate change toward adopting or advancing socially accountable strategies.
Conclusion Rapid evidence narratives that summarize and mobilize evidence on key social accountability topics further the understanding of social accountability in family medicine and in other settings where family physicians work. Mapping actions across the micro, meso, and macro levels of care is a practical way to link front-line, bottom-up actions with a top-down social accountability strategy.
Imagine being a family physician in a large interdisciplinary primary care practice. The organization’s board of directors passes a motion (macro level) that directs the administration, under its social accountability mandate, to become an antiracist health institution (meso level). An antiracism policy (meso level) is created, but admittedly this is a new, unfamiliar, and uncomfortable topic. There is confusion about what to do on the front line of care (micro level) and there are concerns about the policy’s shortcomings. Antiracism is an expectation in any social accountability strategy, but it can be challenging to navigate this and other unfamiliar topics, creating barriers for the implementation of social accountability strategies.1 The path to being an antiracist institution would be clearer with a practical, evidence-based approach linking “top-down” policies with “bottom-up” actions across macro, meso, and micro levels of care.
Social accountability in health care is an equity-oriented strategy that reflects the importance and obligation of understanding local community needs, responding to them, and assessing the effectiveness of such efforts.1-11 This obligation extends to communities and people who are marginalized, who are underserved, and who experience inequity, and it touches on numerous key topics such as antiracism, community engagement, and the social determinants of health.1,4,5,8,10-15 Although this topic has gained in popularity, the application of social accountability in health care service delivery and in family medicine has been limited.1,4,16 This may be in part owing to the absence of a comprehensive understanding of social accountability in this context.1,4,14,17
Despite these challenges, the application of social accountability in health care service delivery and in family medicine has been advocated for and attempted as both top-down and bottom-up strategies with some success. Top-down approaches tend to focus on institutionally comprehensive or system-level strategies,1,4,5,7-9,11-13,16,18-20 while bottom-up initiatives focus more on front-line actions that have a direct impact on patients.15,21 Both approaches have shared aspirations, and combining them is an opportunity to fortify links between front-line actions and the system-level policies, processes, and structures needed to support them.
In family medicine, a strong and growing desire exists for social accountability.5,7-9,12,13,15,18 Since 2012 the College of Family Physicians of Canada has been advised by a Social Accountability Working Group.18 The need for social accountability has also been highlighted in the Patient’s Medical Home vision of care.20 It has been articulated across the micro, meso, and macro levels of health care in family practice12,13,15 and it is gaining traction in other settings, such as in emergency departments, where family physicians also work.1,4,5,7,11 There is an opportunity to accelerate transformation toward greater social accountability in family medicine by providing tools, such as rapid evidence narratives,22,23 that can bolster the comprehensive understanding and application of social accountability concepts in this context.
Objective of program
The objective was to develop rapid evidence narratives on key social accountability topics that summarize and help mobilize current and emerging evidence for practical use in social accountability strategies that family physicians can incorporate into their practices, family medicine clinics, and other settings in which they work.
Program description
The SAFE (Social Accountability as the Framework for Engagement) for Health Institutions project24 aims to promote the adoption of a social accountability framework in health care service delivery. To accomplish this, the SAFE for Health Institutions project team developed a comprehensive evaluation tool, which includes a framework of 253 top-down social accountability standards.25 A preliminary list of key topics corresponding to the SAFE for Health Institutions evaluation tool standards was identified by the project’s principal investigator (A.A.), co-principal investigator (E.C.), and a medical learner (N.R.) (Box 1). Five topics were selected for the first round of rapid reviews based on perceived need and the research team’s expertise, lived experiences, and diversity, with plans to develop rapid evidence narratives for all identified and emerging topics linked to social accountability.
Key topics linked to the SAFE for Health Institutions’ comprehensive social accountability standards
Community health needs assessment
Social determinants of health*
Care for people who are marginalized (eg, newcomers, individuals living with poverty, people who are unhoused)
Environmental accountability*
Diversity, equity, and inclusiveness
Racism and systemic racism*
Cultural safety*
Health equity
Community engagement*
Partnerships with key stakeholders
Social return on investment
Health workforce and human resource planning
Interprofessionalism
Lived experience
Health professional education
Primary care
Social support services
Socially accountable research
Advocacy
Impact on population health indicators
SAFE—Social Accountability as the Framework for Engagement.
↵* Selected for the first round of rapid evidence narratives.
Literature searches for each of the 5 topics were conducted between June and November 2021 for articles preferably published within 10 years dating back from June 2021. Relevant articles were identified using a combination of structured database searches and hand searches using the Northern Ontario School of Medicine University library’s e-Journal database (eg, PubMed, Science Direct, National Center for Biotechnical Information), Google, and Google Scholar. Search terms were specific to each key topic. Titles, abstracts, and full articles were reviewed for inclusion criteria (Box 2) and assessed for bias. Evidence was extracted and synthesized into narratives. Rapid evidence narratives were structured to articulate each topic’s contextual connection to social accountability and to connect practical front-line, bottom-up actions with corresponding considerations for top-down standards across the micro (patient-provider), meso (health care and community environments), and macro (political and policy contexts) levels of care. These narratives capture how top-down social accountability standards can be addressed with bottom-up or front-line actions that directly affect patients. Rapid evidence narratives are being further tailored to the context of family medicine for a series of articles in Canadian Family Physician, the first of which appears in this issue (page 594).26
Inclusion criteria for the narrative literature review
Local (Canadian) and global perspectives
Conceptual relevance
English language
Published in past 10 years (from June 2021 dating back to June 2011)
Fully accessible and available online
Literature types (peer-reviewed publications, reports, grey literature, news articles, published commentaries from medical experts)
No obvious bias
Developmental evaluation27-29 is planned to facilitate assessment and continuous quality improvement and to inform further content development. Data will be collected using feedback forms and any relevant discussion, such as exchanges via email and at project meetings, and involving individuals who develop or access the rapid evidence narratives. These data will then be thematically analyzed.
Results
Key topics linked to the SAFE for Health Institutions evaluation tool framework of social accountability standards that were selected for the first round of rapid evidence narratives30 include the following:
racism as a determinant of health and health care;
cultural continuity—practising cultural safety in health care;
community engagement—the foundation for community-centred care;
environmental accountability of health institutions—why it matters; and
interventions targeting the social determinants of health.
Developmental evaluation data are being collected as the rapid evidence narratives are disseminated and implemented by knowledge users on a continual basis.
Discussion
These rapid evidence narratives build on the momentum and application of social accountability approaches in family medicine, which have previously been articulated across micro, meso, and macro levels of care.12,13,15 They also tie together proposed bottom-up and top-down social accountability strategies.4,5,7-9,24 Otherwise, there are no other programs that focus on key social accountability topics that link top-down policies, processes, and structures with bottom-up, front-line actions.
Tools such as the SAFE for Health Institutions evaluation tool and rapid evidence narratives25,30 can help with the implementation of social accountability in family medicine practices, and in other settings where family physicians also work, by filling in knowledge gaps and demonstrating how to address key topics. Articulating front-line, bottom-up actions that correspond to top-down standards across the micro (patient-provider), meso (health care and community environments), and macro (political and policy contexts) levels of care is a practical and comprehensive approach to overcoming barriers and to navigating new, challenging, or unfamiliar topics. This can be particularly helpful to family physicians and to those responsible for the administration of and access to primary care, who aspire for social accountability but may not know what steps to take to navigate the complex changes and topics. Family physicians may also find that these rapid evidence narratives detail how to tackle challenging or unfamiliar topics linked to social accountability such as racism, cultural safety, or the environmental accountability of their practices across the spectrum of their work.
While the list is not exhaustive, 20 key social accountability topics were identified and 5 were selected for the first round of rapid evidence narratives.30 Some of these topics, such as caring for people who are marginalized, are broad and will likely need to be more narrowly focused along the lines of “caring for people who are marginalized owing to [eg, poverty].” Each narrative’s findings will be described in greater detail in future articles and will touch on transformative concepts that must be considered in any social accountability strategy. For example, a key take-away message from our exploration of the experience of racism in health care was that there is a need for antiracism standards of care. Diving into cultural safety unearthed how a patient’s cultural identity should flow continuously and unabatedly throughout health care interactions. Exploring community engagement focused on how to move beyond patient-centred care toward community-centred care. Looking into environmental accountability highlighted how supply chains and corporations that support health care contribute to global warming and single-use waste items. It was also evident that social accountability strategies must address the social determinants of health.
Limitations
Rapid narrative review methodology was chosen to capture the breadth, depth, and variety of literature for each topic.22,23 This was not a systematic review of the literature, which often lacks an equity lens and excludes qualitative articles.31 Social accountability in health care service delivery also remains an evolving and innovative area of activity. Key topics were identified based on the SAFE for Health Institutions evaluation tool framework of standards, but other emerging key topics will have to be considered as more is understood about social accountability in family medicine and other health care service delivery settings.
The SAFE for Health Institutions project team will continue to develop rapid evidence narratives based on the growing list of key social accountability topics and to advocate for their use as part of a comprehensive social accountability tool kit. Developmental evaluation data will be used to support continuous quality improvement.
Conclusion
Developing rapid evidence narratives that summarize and mobilize evidence on key social accountability topics furthers the comprehensive understanding of social accountability in family medicine practice and in other settings where family physicians work. Mapping actionable steps across the micro, meso, and macro levels of care provides a practical way to link front-line, bottom-up actions to top-down social accountability standards. Family medicine clinics and interprofessional primary care practices, as well as individual family physicians, other health care providers, health care administrators, and policy-makers, may find these rapid evidence narratives helpful in supporting their social accountability strategies. They are available as part of the SAFE for Health Institutions project tool kit (https://safeforhealthinstitutions.org).24
Acknowledgment
We thank the Northern Ontario Academic Medical Association, the Northern Ontario School of Medicine University, the Centre for Social Accountability, and the Health Sciences North Research Institute for their support of the SAFE for Health Institutions project.
Notes
Editor’s key points
There is a growing need and support for efforts to address social accountability in family medicine.
The SAFE (Social Accountability as the Framework for Engagement) for Health Institutions project team has developed a comprehensive framework of standards that family physicians can use to implement social accountability strategies in their work.
To support these standards, rapid reviews of key social accountability topics were undertaken with findings to be reported in a practical format: rapid evidence narratives.
Identifying actions across micro, meso, and macro levels of care can inform “bottom-up” actions and “top-down” policies that family physicians can implement in practice and across various work settings.
Points de repère du rédacteur
Les initiatives destinées à s’attaquer au problème de la responsabilité sociale en médecine familiale sont de plus en plus nécessaires et soutenues.
L’équipe du projet SAFE (Social Accountability as the Framework for Engagement [Responsabilité sociale comme référentiel pour la mobilisation]) pour les établissements de santé a conçu un cadre exhaustif de normes dont les médecins de famille peuvent se servir pour mettre en œuvre des stratégies de responsabilité sociale dans leur pratique.
À l’appui de ces normes, des revues rapides des principaux enjeux de responsabilité sociale ont été réalisées. Leurs constatations ont été présentées dans un format pratique, soit un sommaire narratif des données probantes.
Le recensement des mesures possibles aux niveaux micro, méso et macro de soins est susceptible d’orienter des interventions « ascendantes » et des politiques « descendantes » que les médecins de famille peuvent mettre en œuvre en clinique et dans divers milieux de travail.
Footnotes
Contributors
All authors contributed to the design of the program, identification of key topics, review of the literature, and preparation of the program description and rapid evidence narratives.
Competing interests
None declared
This article has been peer reviewed.
Cet article a fait l’objet d’une révision par des pairs.
- Copyright © 2023 the College of Family Physicians of Canada
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