Health care system partners in BC are shifting away from siloed approaches to the planning and delivering of primary care and toward approaches that are socially accountable[1] and reflect the needs and strengths of all health partners: citizens, clinicians, policymakers, educators, and linked sector and health administrators, with a particular focus on First Nations priorities[2] (we use BC to refer to a geography, and acknowledge that most of what is referred to as BC is unceded First Nations territories). With this shift comes a strong step by health care partners toward one another, which is resulting in exciting and challenging collaboration opportunities.

Northern BC has long been a leader in health care system collaboration and providing team-based care. The emergence of team-based primary care networks[3] across the province provides a framework and set of aspirations that are facilitating important further partnership work in the North, evidenced by periodic engagement, planning summits, and multipartner workshops. At the same time, the emergence of primary care networks also creates challenges and new collaborative opportunities in the effort to reconcile a provincial effort with local realities and priorities.

One such collaboration activity took place at a northern rural health summit in 2018. We describe this multipartner workshop, with a focus on the design process and methodology, and the qualities of the gathering. We also provide a summary of results and reflect on the journey ahead to developing a holistic care system that is socially accountable,[1] culturally safe,[4] and relationship based. By sharing the process and outcomes of this workshop, health care system partners across BC will be better equipped to engage in health care system transformation that is centred on diverse perspectives on primary care design; is grounded in appreciation and respect for Indigenous ways of knowing, being, and doing; and provides a First Nations leadership role in health care system transformation going forward.

Background

To address health inequities, health care system partners from the North have consistently worked together to create an integrated, holistic, primary care system.[5] These partners are generally aligned with the view that primary care in the North needs to move toward a holistic care system that is not only team based but also socially accountable,[1] culturally safe,[4] and relationship based. To achieve health care system transformation and shift power from the existing colonized system of care toward a holistic system of care, a series of partnership development and strategies workshops were designed with key leadership from the First Nations Health Authority, northern divisions of family practice, Doctors of BC, Northern Health, and the Rural Coordination Centre of BC.

The first of these workshops was held in Smithers on the unceded Gidimt’en territory of the Wet’suwet’en First Nation from 19 to 20 July 2018. The purpose of this workshop was to:

• Engage in dialogue and deliberation regarding health care system improvements to allow for the best holistic patient care across the North.
• Build relationships between and among First Nations and health care system partners to enhance health services across the North.
• Advance priority areas regarding health care system transformation and commit to short-term action steps.

Workshop design

When the decision to pursue health care system transformation was established and the call for a partnership development and strategies workshop was made, organizers declared a desire to work in a participatory, relationship-based, equity-focused way. The Partnership Pentagram+ model[2,6] [Figure 1] was used to inform meaningful collaboration, with a focus on creating an experience that amplified social accountability and First Nations values and perspectives. The model, “embraces all partners simultaneously with an appreciative inquiry approach to build upon existing strengths [as] an effective route to positive systems change.”[7] It expands on Boelen’s Partnership Pentagram by including the linked sector, defined as not-for-profits and organizations involved in building healthy communities.[2] By aligning with the Partnership Pentagram+ model, health care system partners of the North could work together to move dialogue and planning away from the typical, colonized, top-down approach to workshop design toward an appreciative inquiry[1] approach rooted in participation, inclusion, and knowledge sharing.

Two-eyed seeing[8] was also used to guide the workshop design, meaning that the methodology strongly focused on centring activities on traditional wellness practice and access to care provided by Indigenous traditional wellness practitioners while still valuing Western perspectives.

The Partnership Pentagram+ model was one important facet to participatory planning; using an equity-focused, intersectional approach was also imperative. Historically, people who identify as men have dominated the health leadership space;[9,10] however, women represent 80% of health service sector workers.[11] Additionally, First Nations people experience disproportionally negative health outcomes due to systemic barriers, such as racism, in health care,[12,13] and First Nations health leaders are frequently not included in the planning processes, or are included in a tokenistic way.[14]

To address these inequities, Indigenous female health leaders were intentionally at the forefront of all workshop planning processes to ensure that gender and racial power imbalances were addressed and the planning work was grounded in appreciation and respect for Indigenous ways of knowing and being. A working group was formed, which facilitated preworkshop engagement activities, including interviews, First Nations community engagement, and an environmental scan.

Based on the information obtained from the preworkshop engagement process, a preliminary agenda was formed, and five priority areas were established:

Catchment and patient flow: understanding the pattern of patient-doctor usage, the level of engagement with doctors across different geographical locations in Northern BC, and whether services provided across the region are equitable.

First Nations engagement: including First Nations as part of the integrated health care system team, and ensuring that health care is culturally safe and integrates traditional healers and engages Elders.

Health and human resource needs and development directions: including a focus on the potential for collaboration among partners to address ongoing human resource shortages in the North.

Team-based care: moving away from the conventional health care system to a new integrated, team-based system of care.

Stakeholder engagement: understanding the different roles in team-based care and the most appropriate level of involvement to avoid burnout.

The agenda was sent to all workshop invitees, and an opportunity to share feedback was provided to allow for the maintenance of transparency and to guarantee that all participants had the same information prior to the workshop. To further enable meaningful collaboration, a range of supports, such as honorariums and travel assistance, were offered to reduce participation barriers and facilitate inclusion at the workshop.

Workshop event

By engaging in an intentional workshop development process that centred on diverse perspectives, social accountability, cultural safety, and relationship building, the stage was set for collaborative work and systems change. More than 70 participants attended the gathering throughout the 2-day event, including partners from Northern Health, the First Nations Health Authority, northern divisions of family practice, medical staff associations, the Ministry of Health, academia, First Nations communities, and the community at large.

The first day of the event was led and facilitated entirely by female leaders from the First Nations Health Authority. As a result, a strong presence of traditional medicine and ways of healing were incorporated into the workshop to exemplify a way to shift from the existing colonized health care system toward a more culturally safe system of care. For instance, at the workshop entrance, there was a table with a thoughtful curation of medicines of the region, such as cedar and sage, and an ethnography—Our Box Was Full—which explores the struggle of the Gitxsan and Wet’suwet’en peoples to “prove they existed.” By sharing Our Box Was Full with participants, workshop organizers were respectfully honoring the land on which the workshop was being held, and were inviting the participants to recognize the pathways to wellness and health that the Wet’suwet’en First Nation and Gitxsan Nation have been practising since time immemorial on their territories. Participants were also invited to partake in traditional wellness sessions with traditional healers from the Adah’ Dene Cultural Healing Camp Society. Workshop participants expressed gratitude for this opportunity to experience traditional healing and be shown how traditional medicine can be a part of a holistic health care system. In the words of one participant, “It was an honor to be able to directly access traditional wellness care in the context of our workshop. It helped me better understand how this care can be offered alongside traditional primary care. It also helped me relax and get grounded in positive ways.”

During the opening remarks, the First Nations Health Authority ensured that the event would be framed with an Indigenous worldview and perspective by inviting an ongoing dialogue about cultural safety and humility.[4] Everyone was encouraged to partake in a cultural safety and humility pledge in order to meaningfully participate in the work [Figure 2].

A series of presentations followed, which were equally connected to Indigenous ways of being, knowing, and doing. Information was shared about First Nations Health Authority operations, traditional wellness practices in health care, and cultural safety, humility, and trauma-informed care.

The second day focused on partnership-based dialogue using the Breathing and Weaving model [Figure 3], an adaptation of the appreciative inquiry method, to discuss the five key priority areas that were identified before the workshop (catchment and patient flow, First Nations engagement, health and human resources, team-based care, and stakeholder engagement). Four dialogue rounds were held:

1. Discover (partners): What does success look like now in regard to the given priority area? What does success look like for patients and community care? How do we build on this success?
2. Dream (peers): What are the implications of dialogue round 1 for your work moving forward?
3. Design (partners): What short-term practical actions can we perform to help us make progress toward our destination in 1 to 2 years?
4. Deliver (peers): What can we commit to doing that will contribute to implementing the actions identified in dialogue round 3?

Each round was supplemented with episodic whole group discussions. The conversations alternated between discussing priority areas for partnership group and peer group commitments/priority action items. Partnership groups consisted of people from different organizations or groups coming together to discuss one of the five priority areas. Peer groups involved only people from the same organization or group to narrate and theorize about each priority area. The four rounds of dialogue started and ended with plenary sessions, and were completed in 1 day.

Each of the six peer groups assigned peer members to attend one of the five priority partnership discussions to ensure that peers from across the six groups participated in each priority area [Figure 3]. Peers then reported on the discussions of each priority area partnership group and had a specific peer-based discussion about possible action items and commitments.

From these conversations, goals were developed, and short-term practical actions were created by both partnership groups and peer groups. By mixing the groups for generative dialogue and then coming back together for organizational, specific, peer-based discussions, the commitments made included the diverse perspectives across stakeholder groups.

Outcomes

Relationship development

The primary focus and outcome of the event was relationship development. Workshop participants shared that by coming together in a socially accountable way, relationships were built on trust, mutual understanding, and respect. This resulted in partners feeling excited to continue the collaboration process, and led to the creation of additional workshops focused on establishing a holistic system of care.

Upon workshop completion, participants (n = 41) were asked to rate their partnership development experience before and after the workshop on a scale of 1 to 5, with 1 being very good and 5 being very poor. There was a marked increase in average scores for both questions, which indicated an increase in knowledge of the work other partners were engaged in and an increased interest in working with other partners [Table 1].

The workshop also supported positive developments in several health care system partner relationships, especially between the First Nations Health Authority and the Rural Coordination Centre of BC. The gathering helped set the groundwork for a signed Memorandum of Understanding, which has facilitated a deepening of service collaboration, especially in virtual services across the province. Moreover, the First Nations Health Authority also invited the Rural Coordination Centre of BC to its Northern Regional Caucus meetings as an expression of inclusion and new collaboration. Because of the workshop, these relationships have established a foundation based on reciprocity and respect that continues to support innovation for enhanced social accountability to First Nations rural patients and providers.

Increased valuing of participatory, decolonized workshop design

Prior to the workshop, participants across stakeholder groups in Northern BC had not come together in a participatory and decolonized way. The event helped establish increased valuing and appreciation of participatory workshop design that includes traditional healing. System partners had the opportunity to experience traditional wellness approaches, and developed a new appreciation for the power of traditional medicine, ceremony, and healing practices. This outcome would not have been possible without intentionally developing a cross-sectoral working group to design the event.

In order to measure the value of coming together collaboratively, participants (n = 41) were asked to rate their experiences on a scale of 1 to 5, with 1 being very good and 5 being very poor [Table 2]. Each category was rated very good or good. This indicated to the organizers that the workshop design and process was successful; therefore, it was used to guide the creation of future partnership development workshops.

Commitments to ongoing collaboration and health care system transformation

Each peer group made a commitment to continue engaging in health care system transformation. While the capacity to work toward health care system transformation varied, each commitment was rooted in developing a holistic care system that is socially accountable, culturally safe, and relationship based.

Because each peer group committed to continuing the work in a good way, the foundation was set for future gatherings to flourish. Since the first event in 2018, two other system-wide workshops have taken place: one in Vancouver (2019), and one virtually (2020). The results of these collaborative efforts included the following:

• Establishment of the First Nations Primary Care Initiative, which was created by the First Nations Health Authority and Ministry of Health, and involves setting up 15 First Nations–led primary care centres.
• Establishment of the Real Time Virtual Services, including the full suite of virtual provider support services, the First Nations Virtual Doctor of the Day, and the First Nations Virtual Substance Use and Psychiatry Services.
• Commitment to conduct ongoing collaborative planning sessions among regional health authorities, Divisions of Family Practice, the Ministry of Health, the Rural Coordination Centre of BC, academic partners, the First Nations Health Authority, and First Nations representatives.

Conclusions

The workshop provided an opportunity for key stakeholders to work toward developing partnerships and strategies to transform health care systems in Northern BC. There was momentum to transform the relationship between the colonized health care system and First Nations; however, the organizers are not blind to the fact that there is still long way to go. Because this work is a lifelong commitment, there will always be more work to be done.

By illuminating to others the process being undertaken in the North, there is hope that health care system partners across BC will be better equipped to engage in health care system transformation that is based on diverse perspectives and is grounded in appreciation and respect for Indigenous ways of knowing, being, and doing.

Competing interests

None declared.

Additional Reading

Daly R. Our box was full: An ethnography for the Delgamuukw plaintiffs. Vancouver, BC: UBC Press; 2005.

Elliot C. Locating the energy for change: An introduction to appreciative inquiry. Winnipeg, MB: International Institute for Sustainable Development; 1999. www.iisd.org/system/files/publications/appreciativeinquiry.pdf.

This article has been peer reviewed.

Dr Markham is the executive director of the Rural Coordination Centre of BC. Ms Hunt is the First Nations Health Authority acting executive director, primary health care and ehealth. Ms Huebert is a registered social worker and formerly a researcher at the Social Planning and Research Council of BC. Mr Graham is the First Nations Health Authority director of operations and planning, primary care, and ehealth.