The 27 real constraints in an FMG schedule.

What gets counted, and what gets missed

Ask an FMG manager how many constraints she handles and she will name about ten. Vacations, each physician's half-days, on-call, offices. Those are the visible ones, the constraints that arrive in her inbox with a person's name attached.

The others never introduce themselves. They were already there when she took the job, they live in a 75-page ministerial program, in an agreement signed between a federation and the government, or in a collective agreement negotiated in Quebec City. Nobody has to announce them, so they stay invisible until the day the establishment records a failure.

The list below separates the two. Each constraint carries its source, and where that source is a public text, it is named with its section.

1. The service offer, locked for twelve months

This first block comes entirely from section 4.6.1.1 of the MSSS funding and professional support program for FMGs, in the version in force from 2026-04-01. It fixes the general shape of the week before anyone has chosen who works when.

1. The 68 hours over seven days. The FMG must offer medical services covering a minimum of 68 hours per week, spread over seven days, with a family physician or an IPSPL present at all times. An FMG that drops below the threshold is no longer eligible for funding.
2. The four-hour minimum block. An opening day must count at least four consecutive hours of services. A three-hour half-day does not count as an open day, even when the weekly total comes out right.
3. The offer spread across all hours. The offer must meet demand and be spread across all opening hours, evenings and weekends included. Packing everyone in from Tuesday to Thursday would give the right number of hours and still be a failure.
4. The holiday period. The FMG must offer a minimum of 44 hours of services per week over six days during the two periods running from 22 to 28 December and from 29 December to 4 January. It is the only drop in hours the year allows, and the dates are fixed.
5. The twelve-month lock. The service offer runs for 12 months or until the next annual review, and no change during the year is possible, for any site. A decision taken in September binds the FMG until its following review.

2. What your level imposes

The program ranks every FMG on a scale of levels calculated from its registered patient population. That level decides what the FMG receives and what it must deliver. It reads like a budget line and it gets settled in the grid.

6. On-site hours by level. A level 1 to 4 FMG that does not offer the 68 hours on site must provide 52 to 64 of them depending on its level and close the gap by agreement, never dropping below five or six days of on-site presence per week. FMGs at levels 5 to 18 must offer the 68 hours on site and cannot use any agreement.
7. The single-partner service agreement. The agreement that closes the gap is concluded with one partner only, and each block it covers must run at least four consecutive hours. An FMG cannot spread its shortfall across three neighbouring clinics according to their availability.
8. Allocated professional staff. The FMG's level fixes the number of full-time equivalents it receives, from one to ten clinical nurses and from one to five psychosocial workers. These people have to appear in the schedule, and their number is not negotiated case by case.
9. Accès-réseau mission hours. An accès-réseau FMG must provide 28 to 84 hours of services per week depending on its level, over seven days, with a daily block of at least four consecutive hours falling between 7 a.m. and 10 p.m. Those blocks are added to the FMG mission hours rather than substituted for them.

3. The blocks that are not yours

Part of the grid is visible and reserved outside the FMG. These four constraints cover blocks the group creates but no longer controls once they are published.

10. Transmission to the orchestrator. The FMG must transmit to the provincial orchestrator, through an MSSS-certified EMR, all availability blocks offered under its FMG mission, reorientation blocks included. The schedule stops being an internal document the moment it is published.
11. Publication for the relevance filter. The FMG must make all its blocks public, except reorientation ones, for the provincial relevance filter, and they must be adequately distributed over time. The obligation takes effect twelve weeks after the filter is rolled out in the region.
12. Reorientation blocks from the emergency department. The FMG agrees with the establishment's CEO and the DTMF medical director to receive patients whose emergency-department assessment favours reorientation. Those blocks must be spread across all opening hours, evenings and weekends included.
13. Blocks for the unregistered population. The number of blocks made available to unregistered patients is agreed case by case with the DTMF medical director, in co-management with the establishment's CEO. A block left unused within four hours of the appointment may be reopened to the whole population.

4. The obligations that follow the physician

These constraints do not target the FMG. They target each physician individually and enter the grid through the side door.

14. Particular medical activities. A family physician with fewer than fifteen years of practice commits to twelve hours of AMP per week or the equivalent, per the FMOQ practice guide. Breaching the AMP agreement brings a 30 % reduction on that physician's entire RAMQ billing. Nothing else on the list is this hard to negotiate.
15. The list of available AMP. Which activities are eligible in a region is determined by the territorial department of family medicine, not by the FMG. The FMG inherits the obligation and its content with no say in either.
16. Hospital on-call. Next month's hospital call and AMP obligations often arrive after the FMG schedule is published and the appointments are booked. The FMG does not control that calendar, only the speed at which it corrects its own.
17. The medico-administrative hours bank. The FMG holds a bank of hours for the coordination, medico-administrative and training activities tied to its operation, which the responsible physician distributes among the group's members. Those hours have to land in the grid the same way a clinical block does.

5. The people who do not report to you

This is the family generic tools ignore entirely, because it does not exist in an ordinary company. Five people in your grid follow rules written by somebody else.

18. Two authorities over one grid. Professionals assigned by the establishment practise under the functional authority of the FMG physicians and under the administrative authority and clinical supervision of their own establishment, per section 4.5.3.1 of the program. Functional authority rests with the responsible physician, whom the text explicitly tasks with adapting these resources' schedules to the needs of the patient population.
19. Staff selection, subject to the collective agreement. The program provides that staff are chosen jointly by the establishment and the FMG, but only where the collective agreements in force allow it, and according to the availability of local qualified labour. The proviso does all the work, and it is written into the text.
20. The replacement deadline. For any continuous absence longer than four weeks, the establishment must replace the resource from the first day if the absence was foreseeable, and no later than the first day of the fifth week if it was not. A three-week absence therefore triggers no right to a replacement.
21. The pharmacist bought by the hour. Pharmacist funding varies with the FMG's level and the hourly rate is capped at $85 for the 2025-2026 fiscal year. You buy a number of pharmacist hours, then you place them in the week.
22. The IPSPL's hours. Since 2024-11-01, letter of agreement 389 has governed collaboration between family physicians and IPSPLs, allocating lump sums in proportion to the weekly hours set in the collaboration agreement. Those hours are written into a contract, not into your grid. The group IPSPL's visits also count toward the attendance rate, whose target is 80 %.

6. The only five you write yourself

Here is what remains once the rest is set aside. Five constraints out of twenty-seven, and the only ones a team meeting can actually move.

23. The half-days each physician owes. Every physician has an activity rate at the FMG, and the gap between six tenths and ten tenths structures the whole period. It is an agreement between the group and its members, so it can be revisited.
24. Absences announced in advance. Vacations, conferences, training and phased returns are filed months ahead and are almost always lost in an inbox. A register that belongs to the schedule fixes this better than tighter filing discipline.
25. Requests that arrive after the cutoff. The FMG alone decides what to do with a late request, and having no written rule is itself a rule, the rule of whoever asked first or pushed hardest.
26. Weighted fairness on call. Counting shifts is not enough when two of them fall on a Friday evening and a third on 24 December. The group agrees once on what an evening, a weekend and a statutory holiday are worth, and the discussion then runs on numbers.
27. Rotation and rest. Who takes the Friday 4 p.m. block, and who does no clinic the day after a night on call. No ministerial program says a word about it. The FMG writes it down itself or lives with the fog.

Three kinds of constraint, not one

The twenty-seven are not the same in nature, and treating them alike is the costliest mistake. Hard constraints are physically impossible to break, like a physician who cannot be in two offices at the same hour. Firm constraints can be broken at a known price, like failing the service offer and losing half the operating funding. Soft constraints are preferences the group gave itself, and they bend when they have to.

A tool that puts all three in one basket produces a schedule that looks right and is not. That is exactly what we saw when we handed two real FMG weeks to a general-purpose assistant in our ChatGPT test, which treated a walk-in block as an ordinary shift and then declared every rule satisfied.

The number of constraints is not the problem. The pairs that contradict each other are. A constraint that ties two people together, like a shared office or a collaboration agreement, can conflict with every other constraint of the same kind. Going from ten to twenty professionals doubles the team and multiplies the possible conflicts by far more than two. That is why a file that held at twelve people gives out at twenty.

Take the count in your own FMG

1. Pull up your last published period and, for each cell, write down why it could not have been anywhere else. The list that comes out is your real inventory, and it is almost always longer than the one you would have dictated from memory.
2. Separate the twenty-two from the five. Put everything that comes from a text you did not write on one side, and what the group decided on the other. You will know what the next meeting can address and what it will waste its time on.
3. Sort each constraint into hard, firm or soft, and write down the price of the firm ones. A team that knows a service-offer failure costs 50 % of operating funding makes different trade-offs than a team that does not.
4. Check the ones written down nowhere. Soft constraints often live in one person's head. That is the FMG's real exposure on the day she takes two weeks off.

Where Synchro fits

Synchro builds schedules for medical teams in Quebec while keeping constraints attached to the grid rather than to an inbox. Each physician writes their own in plain French, walk-in blocks and offices are placed at the same time as people, on-call shifts carry a weight instead of a count, and a change becomes visible to the whole team the moment it is made. The product works mostly on the sixth family and on covering the hours in the first.

Now for what it does not do. Synchro holds no patient data and does not replace your EMR, so it transmits nothing to the orchestrator on your behalf. It does not produce your AMP list, does not negotiate your agreement with the DTMF, and does not calculate your attendance rate. Of the twenty-seven constraints, scheduling software touches a solid ten and leaves the rest to the FMG and its partners.

Further reading

• 8 moments that wreck your FMG schedule
• Scheduling and staff retention in an FMG
• FMG schedule management: which tool to choose
• Writing constraints in plain language
• FMG scheduling software: the complete guide