Sunnybrook Academic Family Health Team

Strategic plan 2014-2018

Happy family

Introduction and planning process

In late 2013 the Sunnybrook Academic Family Health Team (SAFHT) initiated a strategic planning process to guide the evolution of the organization and its work in the four years 2014-2018.

With the help of our consulting firm partner, we sent surveys to two key groups of stakeholders – our team members and our external hospital and community partners. The surveys asked respondents to identify strengths, the challenges ahead, and areas for focus. To explore their initial views in addition to the survey, our consultant met with both the Board and our Office Coordinators. Then on March 24th, the Board and team members from various professional perspectives and administrative staff met to consider the findings from the surveys and to identify the main strategic themes to guide the SAFHT’s future direction.

In April, the Board and members of the team further refined this draft plan. In July, all members of the SAFHT had an opportunity to provide their direct feedback by survey, giving additional input and direction.

This Plan is effective as of September 1, 2014. Although this Plan is for four years, it will be reviewed and updated annually.

The Strategic Plan will be the basis of priority-setting by the SAFHT in the future.

Healthcare professional and patients

The external environment

Through conversations and surveys, we identified the following critical and inter-related trends affecting SAFHT and took them into account when developing our strategy:

An aging demographic

The SAFHT offers primary health care in a diverse urban environment. In this community, there is an increasingly aged population who will live longer, in states of both health and illness. Seniors want to live in their homes for as long as possible and receive dependable community supports to meet their physical, social, emotional, nutritional, and caregiver needs. The SAFHT is likely to face significant challenges in providing quality and patient-centred care to this population — especially those 85 years of age or older. Their proportion of SAFHT’s patient mix will grow. SAFHT anticipates a greater demand for house calls and to more persons with multiple health and functional issues. This mode of delivery may decrease the number of patients that can be seen in a single day, and necessitate the development of innovative approaches.

More complex patients

As a result of both the aging population generally and hospitals discharging patients to the community earlier, there is an increasing role for primary care in the care of complex patients. External respondents noted that the SAFHT already has strengths in this area. Nonetheless, given the increase of these patients expected, the SAFHT will be challenged to take a comprehensive approach to their care and in an environment where there is a priority on integration with community partners in the health care system. New approaches to care may be required.

Constrained public resources

Ontario’s slow economic growth has prevented Ontario from balancing its provincial budget. Since health care costs are a huge part of the equation, the government continues to try to curb the annual growth in public health care spending, and transform the publicly-funded health care delivery system to extract more value for dollars spent. The SAFHT depends on public resources to deliver care to patients and any changes in government funding, along with the expected increase in the number of patients, may challenge the SAFHT’s ability to provide excellent patient care.

Increased performance expectations of primary care

The government has signaled that family health care is a priority. Ontario’s Action Plan in 2012 identified faster access to primary care and the introduction of quality measures to family health care as key components of a fully integrated system. Given this priority, there will likely be a continued drive to assure the performance of primary care (and especially of family health teams) and to identify best practices and successes so as to disseminate them into wider practice. This drive for performance improvement is likely to translate to even more benchmarks and expectations for SAFHT and other FHTs from the Ministry and/or the LHINs. Access to primary care is a vital part of government’s efforts to improve coordination of care for high-needs patients such as seniors and people with complex conditions. Nineteen Health Links have been created across the province to encourage greater collaboration and coordination between a patient’s different health care providers as well as the development of personalized care plans. Each Health Link is expected to measure results and develop plans to:

  • Improve access to family care for seniors and patients with complex conditions
  • Reduce avoidable emergency room visits
  • Reduce unnecessary readmission to hospitals shortly after discharge
  • Reduce time for referral from primary care doctor to specialist appointment
  • Improve the patient’s experience during their journey through the health care system

Community integration and NETHL

Related to the issues above, SAFHT maintains strong working partnerships with community organizations and the Community Care Access Centres in both the Toronto Central and Central LHINs. With the push to prevent and manage illness, thereby avoiding or reducing hospitalizations resulting from poor disease management, services such as home care, hospice care, mental health and addictions services, and supportive housing, must work alongside primary care in the home setting. At the time of this planning, the North East Toronto Health Link (NETHL) is identifying the top one per cent of health care users so that care around these patients in particular can be coordinated. The SAFHT is one of the partners in this initiative.

Technology and the digitization of health care

In the wider world of health care, technology is changing how things are done. There is development and greater use of medical technologies, and, in particular, the Electronic Medical Record (EMR). The next step in the system — beyond adoption — is the optimization and ‘meaningful use’ of the EMR at the individual practice, team, and inter-organizational level to take advantage of the full suite of benefits an EMR can provide. For example, at the practice level, the EMR needs to be deployed as a preventative care management tool for patient populations. In addition to EMRs, in some settings smart phones and tablets are enabling health care professionals to communicate more effectively and deliver treatment more quickly.

At the inter-organizational level, there must be inter-operability between systems so health care professionals from different institutions can see and input data. Clearly, new technologies can and will transform provider-patient and provider-provider interactions and redesign care pathways.

Healthcare professional patient

The internal environment: The SAFHT

Organizational capacity and innovation

Respondents in the survey believe that the SAFHT provides exceptional patient-centred care. However, many worry that that the SAFHT will be over-stretched if it cannot prioritize or if it responds to too many external opportunities. For example, certain team members struggle to balance academic productivity with the goal of delivering excellent patient-centred care. Interestingly, SAFHT members believe that the SAFHT is inherently innovative and willing to try new things. Individuals point to past program innovations and speak to innovation as part of the culture. To resolve capacity issues as pressures increase, SAFHT’s innovation culture may help drive new models of the delivery of care and education.

Challenges in information technology (IT)

The SAFHT has been a leader in IT innovation to enhance patient care. The organization implemented a comprehensive approach to the EMR, reviewing all work processes and converting them where possible. Within the academic environment, the SAFHT plays a leadership role regarding use of the EMR. From the survey done in this planning exercise, we learned that there is more to be done in this area. Areas for improvement include electronic communication with patients and advanced usage of the EMR.

We noted concerns to be managed in the sharing of patient information between care providers. We also noted that when it comes to information technology, the SAFHT relies on the IT infrastructure of the Sunnybrook Health Sciences Centre (“the Hospital”) and this has been, at times, problematic.

Profile within the hospital and externally

The SAFHT has strived to increase its profile within the Hospital so as to strengthen communication and understanding between the SAFHT and hospital departments.

With these and other issues and trends in mind, the Board has set direction. Our Strategic Plan for the next four years is as follows:

Mission, vision and values

Our mission

Statement of the SAFHT’s enduring role and why it exists, its mandate:
Providing quality interprofessional primary care for our community in an academic environment

Our vision

What the SAFHT strives to be/accomplish:
Achieving Health Together

Core values

These values and principles are what we believe in and they guide all our decisions and actions:

  • Person-centredness
  • Innovation
  • Respect
  • Quality
  • Prevention
  • Teamwork

Principles to provide focus

The following principles will help us decide where to focus our energies and resources when projects and opportunities come forward. We see the following dimensions as being key to both shape meaningful projects and make decisions regarding priorities:

We prioritize SAFHT opportunities and choose strategies within our Strategic Plan that best:

  • Foster person-centredness
  • Balance the needs of our various patient populations
  • Demonstrate innovation
  • Enhance quality
  • Promote prevention
  • Strengthen interprofessional teamwork
  • Increase accessibility

Baby and mom

Our strategic goals

These priority goals will ensure the SAFHT’s success in its mission and as a FHT:

1. Engaging patients in their own care to optimize their health

We are person-centred and provide primary care throughout the lifespan of our patients. We offer our primary care services in a way that is sensitive and responsive to a patient’s needs, values and preferences. We have long recognized that patients and families should have an active role in making decisions about their own care. This goal is about realizing that vision of empowering and engaging patients to stay well, manage chronic conditions, and to enjoy the optimal quality of life possible for them. As a primary care provider with interprofessional resources, we know that we are best positioned to reinforce the patient’s and family’s goals to stay healthy by supporting the positive habits and lifestyle changes that promote illness prevention and better manage chronic conditions.



1.1. Improve patients’ understanding of the delivery of care by the interprofessional care team

  • Develop a patient education campaign utilizing various methods including the development of the website, pamphlets, open house sessions, etc.

1.2. Embed person-centredness and patient-engagement into the team’s culture and practice

  • Utilize currently trained interprofessional staff to mentor their colleagues in patient self-management approaches

1.3. Empower patients and their families to promote health and prevent and/ or manage chronic conditions

  • Increase opportunities for patients to participate in interprofessional group self-management sessions
  • Increase patients’ awareness of preventative/screening strategies based on age and stage (Ocean tablets, TV screen information, questionnaires)
  • Explore fund raising opportunities with the Sunnybrook Foundation to enhance our programs with this objective

2. Increasing access to quality health care for our patients

Improved access to primary care is a health system priority. This means coordinated 24-hour, 7-day-per-week management of access to appropriate primary care services offered by the SAFHT. This also means access according to need and irrespective of a person’s race, ethnicity, gender, sexual orientation, income, cognitive, and physical ability. We are also mindful of the transitions our patients may experience in their journey of care through the health system.



2.1. Ensure FHT services are available to patients in a timely manner

  • Continue to review and augment after-hours care including interprofessional health care provider (IHP) services and classes
  • Identify back-log issues in services and programs and address them
  • Have all teams move either to an advanced access or carve-out model
  • Improve communication to patients regarding available resources (relates to Goal 1)
  • Utilize all health care providers optimally (at their full scope of practice) to increase access (relates to Goal 5)
  • Evaluate timeliness using regular patient feedback

2.2. Facilitate and support coordination of care for patients in transition

  • Strengthen partnerships with community-based agencies and hospitals
  • Work with specialists to enhance communication and ensure a timely coordinated approach to patient care
  • Continue to work with the Hospital to improve information transfer regarding our patients’ consultations, admittance, discharge and transitions (patient flow)
  • Increase continuity of care for patients seeing residents (booking strategy for residents)

2.3. Improve access to hospital and community-based services re: specialists, diagnostics, programs, etc.

  • Develop a process for dissemination of information of new and available resources
  • Optimize the utilization of the care navigator

3. Responding to the complex care needs of our patients

In an environment where care must be increasingly integrated, we will continue to work with the Hospital and all relevant community partners. Our goal is to strengthen our responsiveness and expertise in care complexity while supporting a broad-based continuum of patient care. Given the team’s ongoing relationship with our patients with complex care needs, we are well-positioned to anticipate their health risks and to recognize any decline. By being located within a large academic and research hospital with access to specialist and diagnostic services, the SAFHT can help prevent and/or minimize adverse outcomes.



3.1. Anticipate increasing health risks for the complex care needs of our patients and plan/ implement risk-reduction strategies

  • Identify on an ongoing basis patients at risk for health decline
  • Use IMPACT as a resource for patients at risk
  • Encourage appropriate use and communication of the Coordinated Care Plan developed by the NETHL

3.2. Optimize community partners in the management of the complex care needs of our patients and in provision of support to their families

  • Increase team’s awareness regarding partners, their services, and how to access them
  • Develop improved pathways and tools to communicate with partner organizations

3.3. Assist our patients with complex care needs to live well and safely at home

  • Continue to develop and expand the homebound seniors program
  • Assess and improve home safety for patients at risk through appropriate use of IHPs and community services
  • Continue to develop OTN-based access to primary care team and specialists for homebound patients

3.4. Support NETHL efforts to better coordinate care to meet the complex care needs of our patients

  • Actively engage in the NETHL

4. Educating and modelling interprofessional primary care for the health care providers of the future

The SAFHT is the setting for a model of primary care that is person-centred and interprofessional. Our approach is about exposing all learners to the various disciplines and demonstrating their value in primary care. We are preparing future physicians and other health care professionals to work in a collaborative interprofessional environment, which will be essential to meeting the increasing complexity of primary care.



4.1. Increase number of non-physician interprofessional learners

  • Identify and implement strategies to enable IHPs to train/mentor learners

4.2. Engage learners in our developing model of team-based care

  • Strengthen orientation of new team members in team-based care with roles and responsibilities, guided by role-modeling and regular feedback
  • Increase exposure of learners to other professionals/disciplines – learning with and from each other
  • Diversify and strengthen mentorship and tools to optimize the learning from other disciplines
  • Increase the frequency and awareness of embedded health care providers, including clearly labeling embedded providers in PSS
  • Ensure learners are engaged and take an active role in interprofessional and “Doing It Better” rounds
  • Provide opportunities for learners to take on more responsibility related to demonstrating their competencies in team-based care

4.3. Align with the academic mission of the Sunnybrook Department of Family & Community Medicine

  • Align SAFHT educational activities as appropriate

Care room

Our enabling goals

The following activities are the enabling and necessary supports and processes required organizationally to be successful. These goals support the pursuit of our strategic goals:

5. Optimizing interprofessional roles and scope of practice to deliver comprehensive care to benefit our patients

The SAFHT will ensure the most appropriate and timely care is provided by the most appropriate provider. We will derive the greatest value for patients from our team through optimizing and coordinating our interprofessional care.



5.1. Ensure all team members work to their full scope of practice

  • Establish clear accountabilities at the team and individual practice level, facilitating each team member’s full scope of practice
  • Optimize opportunities for individuals to carry out the full scope of their profession
  • Continue to develop and reinforce our interprofessional culture
  • Encourage continuing education to develop scope of practice (relates to Goal 7)

5.2. Ensure all team members understand the roles and contributions to care of various disciplines

  • Share each discipline’s best practices
  • Strengthen orientation/education/training to ensure team members understand the full scope and expectations of each discipline in the FHT

5.3. Ensure patients receive care from the appropriate provider

  • Develop a well-functioning fluid process for interprofessional care e.g. effective referrals to IHPs, patient group classes, and embedded IHPs in clinics
  • Support team members in identifying opportunities for interprofessional care
  • Educate the patients on resources available so patients can initiate the team approach (relates to Goal 1)

6. Practicing innovation and quality improvement in patient care

The SAFHT is already formally committed to and pursuing quality improvement successfully. In the next few years, we expect to increasingly improve quality and innovate in our delivery of health care. This goal involves pursuing evaluation to ensure our services are effective, integrating evidence-based best practices (including regarding interprofessional approaches), supporting change and innovation ideas and linking them with indicators, and setting and meeting appropriate quality improvement targets and measures for the team. People should receive care that is both informed by the best available scientific information and effective in its delivery.



6.1. Further integrate quality and evaluation into our activities

  • Meet our quality improvement plan commitments annually
  • Educate the staff regarding the value of quality improvement and the FHT’s support of their efforts
  • Develop a platform or vehicle for exploration of quality improvement ideas and strategies for decision-making and implementation

6.2. Use FHT-wide projects as opportunities to advance the academic mission

  • Identify clinical projects that have academic potential for further study
  • Educate the team about current research and educational scholarship taking place involving members of the FHT

6.3. Enhance knowledge dissemination within the FHT and externally

  • Amongst team members
  • To learners
  • To/from other FHTs
  • Disseminate awareness of innovation and research and learnings from the FHT
  • Learn from related innovation and improvement initiatives externally to improve our work
  • Collaborate with hospital, community and university partners to enhance knowledge sharing

7. Strengthening the FHT organization and presence

The SAFHT will continue to strive to be a great place to work and practice so that we attract and retain high-quality team members. In this busy environment, strong ongoing internal and external communications are critical. Internally we will strive to enhance communication and information flows. Externally, in relationship to our community and our partners, through consistent messaging we will seek to present and demonstrate the brand of SAFHT as about professionalism, excellence and transparency. To support our strategic goals, information management and technology will continue to be utilized and improved.



7.1. Support the members of the team in their continuous learning

  • Continue to encourage team members to seek out learning opportunities
  • Regularly identify learning opportunities for the team to access
  • Support dedicated time to continuous learning
  • Develop effective ways of dissemination of what was learned (relates to Goal 6)

7.2. Improve the effectiveness of internal and external communications

  • Within the FHT:
    • Focus on appropriate use of patient care communications both electronically and through others means
    • Utilize team meetings effectively
  • Continue to enhance primary care-hospital relationships and partnerships with the local community
  • Strengthen communications with patients through enhancement of web site, revision of the patient pamphlet, etc.
  • Maintain good communications with the Ministry

7.3. Optimize the use of information technology to support our goals

  • Continue to explore ways to use electronic medical technology (EMT) more effectively
  • Enable patient electronic communications on a non-urgent basis
  • Further integrate technology solutions which support chronic disease prevention and management
  • Further develop the IT support for innovation, quality and research
  • Continue to develop the potential of the website (as noted above in various other objectives)

7.4. Build the profile of the SAFHT

  • Develop regular means of collecting and utilizing feedback from our patients and stakeholders
  • Implement brand strategies
  • Optimize the value of presentations by SAFHT team members at conferences, etc.
  • Continue to develop communication strategies directly and through partnerships


The SAFHT’s primary purpose is to provide quality interprofessional primary care for our community in an academic environment. Our patients are at the core of everything we do and every decision we make. In this Strategic Plan, mindful of the needs of all our patients and of our care team, we have set a path to build upon our strengths while responding to the changing health care system, rapidly advancing technologies, and evolving knowledge regarding primary care.

We look forward to further integrating this strategy’s components into our commitments and processes and working with our partners to achieve our mission and vision.