Step 2: Assess/Plan

Determine where you are, where you want to be and how to get there

A good place to start is to determine who exactly is on the team. Who are your patients/clients/residents? What are their care needs? Who on the team addresses what need? Teams often miss this step and forget to include critical members of the team. In order for Collaborative Care to be most effective and benefit everyone involved, everyone needs to be engaged.

Team Assessment

Determine where a team’s strengths and desired areas for improvement lie. Before you can determine where you’re headed on the Collaborative Care journey, you must first discover where you are.

There are a number of tools available to assist teams with assessment. A range of assessment options are provided; it is not necessary to use them all.

Two interactive activities to assist in the Collaborative Care assessment have been piloted with teams in the Winnipeg Health Region:

  • Appreciative Inquiry
  • Completion of the IP-COMPASS tool

Appreciative Inquiry (AI)

The AI process is about exploring and understanding what factors are in place when a team, program or organization is functioning at its best. It builds on the aspects of ‘what is working well’ and involves 4 steps: discovery, dreaming, design and destiny.

A half-day AI session has been developed by the Winnipeg Health Region Research and Evaluation Unit to assist team members in the first two steps of AI – discovery and dreaming. From this interaction, team members can then build on the information to develop their action plan (design) and create their desired future (destiny).

For additional information on the AI process, refer to:

Reed, J. (2007). Appreciative Inquiry. Thousand Oaks, CA: SAGE Publications.


The IP-COMPASS tool was developed by the University of Toronto and the Sick Kids Institute to assist teams to rate themselves in four constructs relating to interprofessional care and interprofessional education.

This tool builds on the information gathered from the AI process as it looks at specific team and organization processes and structures needed to support effective Collaborative Care.

If you are interested in having your team use the IP Compass Tool, contact Ivy Oandasan at or Kathryn Parker at

Other Assessment Tools of Interest

There are a number of tools and self-survey instruments that have been developed and are discussed in the literature. These tools can be completed by individual team members to gain an understanding of people’s attitudes towards Collaborative Care and how they view the team’s Collaborative Care processes.

These tools can be used prior to the start of the team’s work on improving their Collaborative Care and at various points along the journey to measure change and improvements.

Canadian Interprofessional Health Collaborative (CIHC/CPIS). (2010). A national interprofessional competency framework. Vancouver, BC: College of Health Disciplines, University of British Columbia.

Coogle, C. L., Parham, I. A., Cotter, J. J., Welleford, E. A., & Netting, F. E. (2005). A professional development program in geriatric interdisciplinary teamwork: Implications for managed care and quality of care. Journal of Applied Gerontology, 24(2), 142-159. doi:10.1177/0733464804271551

Heinemann, G. D., Schmitt, M. H., Farrell, M. P., & Brallier, S. A. (1999). Development of an attitudes toward health care teams scale. Evaluation and the Health Professions, 22(1), 123-142. doi:10.1177/01632789922034202

Hepburn, K., Tsukuda, R., & Fasser, C. (1998). Team skills scale, 1996. In E. L. Siegler, T. Hyer, T. Fulmer & M. Mezey (Eds.), Geriatric interdisciplinary team training (pp. 264-265). University of Michigan: Springer.

John A. Hartford Foundation Inc.GITT – geriatric interdisciplinary team training program. Retrieved 07/27, 2011, from

Kenaszchuk, C., Reeves, S., Nicholas, D., & Zwarenstein, M. (2010). Validity and reliability of a multiple-group measurement scale for interprofessional collaboration. BMC Health Services Research, 10 doi:10.1186/1472-6963-10-83

Kivimäki, M., Vanhala, A., Pentti, J., Länsisalmi, H., Virtanen, M., Elovainio, M., & Vahtera, J. (2007). Team climate, intention to leave and turnover among hospital employees: Prospective cohort study. BMC Health Services Research, 7 doi:10.1186/1472-6963-7-170

Long, D. M., & Wilson, N. L. (2001). In Long D. M., Wilson N. L. (Eds.), American congress on rehabilitation medicine. houston geriatric interdisciplinary team training curriculum. Houston, TX: Huffington Centre of Aging – Baylor College of Medicine.

Develop an Action Plan

Taking the information gathered from the team assessment activities, the team then develops an action plan.

Click here for an example of an Action Plan Template that the team can use to document the intended goals, activities and timelines.