Related Articles

Background

Effective implementation of change in healthcare organisations involves multiple professional and organisational groups and is often impeded by professional and organisational boundaries that present relatively impermeable barriers to sharing knowledge and spreading work practices. Informed by the theory of communities of practice (CoPs), this study explored the effects of intra-organisational and inter-organisational boundaries on the implementation of service improvement within and across primary healthcare settings and on the development of multiprofessional and multi-organisational CoPs during this process.

Methods

The study was conducted within the Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester—a collaborative partnership between the University of Manchester and local National Health Service organisations aiming to undertake applied health research and enhance its implementation in clinical practice. It deployed a qualitative embedded case study design, encompassing semistructured interviews, direct observation and documentary analysis, conducted in 2010–2011. The sample included practice doctors, nurses, managers and members of the CLAHRC implementation team.

Findings

The study showed that in spite of epistemic and status differences, professional boundaries between general practitioners, practice nurses and practice managers co-located in the same practice over a relatively long period of time could be successfully bridged, leading to the formation of multiprofessional CoPs. While knowledge circulated relatively easily within these CoPs, barriers to knowledge sharing emerged at the boundary separating them from other groups existing in the same primary care setting. The strongest boundaries, however, lay between individual general practices, with inter-organisational knowledge sharing and collaboration between them remaining unequally developed across different areas due to historical factors, competition and strong organisational identification. Manipulated emergence of multi-organisational CoPs in the context of primary care may thus be problematic.

Conclusions

In cases when manipulated emergence of new CoPs is problematic, boundary issues could be addressed by adopting a developmental perspective on CoPs, which provides an alternative to the analytical and instrumental perspectives previously described in the CoP literature. This perspective implies a pragmatic, situational approach to mapping existing CoPs and their characteristics and potentially modifying them in the process of service improvement through the combination of internal and external facilitation.

Background

Most services provided by health and social care organisations for older people living at home rely on interprofessional working (IPW). Although there is research investigating what supports and inhibits how professionals work together, less is known about how different service models deliver care to older people and how effectiveness is measured. The aim of this study was to describe how IPW for older people living at home is delivered, enacted and evaluated in England.

Method

An online survey of health and social care managers across England directly involved in providing services to older people, and a review of local strategies for older people services produced by primary care organisations and local government adult services organisations in England.

Results

The online survey achieved a 31% response rate and search strategies identified 50 local strategies that addressed IPW for older people living at home across health and social care organisations. IPW definitions varied, but there was an internal consistency of language informed by budgeting and organisation specific definitions of IPW.

Community Services for Older People, Intermediate Care and Re-enablement (rehabilitation) Teams were the services most frequently identified as involving IPW. Other IPW services identified were problem or disease specific and reflected issues highlighted in local strategies. There was limited agreement about what interventions or strategies supported the process of IPW. Older people and their carers were not reported to be involved in the evaluation of the services they received and it was unclear how organisations and managers judged the effectiveness of IPW, particularly for services that had an open-ended commitment to the care of older people.

Conclusion

Health and social care organisations and their managers recognise the value and importance of IPW. There is a theoretical literature on what supports IPW and what it can achieve. The need for precision may not be so necessary for the terms used to describe IPW. However, there is a need for shared identification of both user/patient outcomes that arise from IPW and greater understanding of what kind of model of IPW achieves what kind of outcomes for older people living at home

Background

Frail elderly people need an integrated and coordinated care. The two-armed study "Continuum of care for frail elderly people" is a multi-professional and multidimensional intervention for frail community-dwelling elderly people. It was designed to evaluate whether the intervention programme for frail elderly people can reduce the number of visits to hospital, increase satisfaction with health and social care and maintain functional abilities. The implementation process is explored and analysed along with the intervention. In this paper we present the study design, the intervention and the outcome measures as well as the baseline characteristics of the study participants.

Methods/design

The study is a randomised two-armed controlled trial with follow ups at 3, 6 and 12 months. The study group includes elderly people who sought care at the emergency ward and discharged to their own homes in the community. Inclusion criteria were 80 years and older or 65 to 79 years with at least one chronic disease and dependent in at least one activity of daily living. Exclusion criteria were acute severely illness with an immediate need of the assessment and treatment by a physician, severe cognitive impairment and palliative care. The intention was that the study group should comprise a representative sample of frail elderly people at a high risk of future health care consumption. The intervention includes an early geriatric assessment, early family support, a case manager in the community with a multi-professional team and the involvement of the elderly people and their relatives in the planning process.

Discussion

The design of the study, the randomisation procedure and the protocol meetings were intended to ensure the quality of the study. The implementation of the intervention programme is followed and analysed throughout the whole study, which enables us to generate knowledge on the process of implementing complex interventions. The intervention contributes to early recognition of both the elderly peoples' needs of information, care and rehabilitation and of informal caregivers' need of support and information. This study is expected to show positive effects on frail elderly peoples' health care consumption, functional abilities and satisfaction with health and social care.

Trial registration

ClinicalTrials.gov: NCT01260493

Purpose

To understand the needs of information in the collaboration between health personnel in hospitals and care nursing personnel in municipal care in the process of discharging care-needing older patients from hospitals.

Theory

The analytical perspective is a process of patient transition, in which responsible actors in health and municipal care have to collaborate in certain patterns, within a tight time schedule, restricted by the different organizational framework of a hospital or a municipality within which individual actors are situated.

Methods

Step 1: Qualitative studies with nursing personnel in six municipalities and nurses in the hospitals serving the actual municipalities. Step 2: A survey addressed to key informants in municipal care in a representative sample of Norwegian municipalities.

Results

The formal routines of information exchange associated with these kinds of discharges are too slow and out of phase with informational needs. Seventy percent of our respondent stated that information delivered through formal routines had already been collected by informal contacts. Formal routines were usually weakest for patients to be taken care of in their own homes—where the need for information in many cases was greater than for patients going to local institutions.

Background

Prior studies measuring fidelity of complex interventions have mainly evaluated adherence, and not taken factors affecting adherence into consideration. A need for studies that clarify the concept of fidelity and the function of factors moderating fidelity has been emphasized. The aim of the study was to systematically evaluate implementation fidelity and possible factors influencing fidelity of a complex care continuum intervention for frail elderly people.

Methods

The intervention was a systematization of the collaboration between a nurse with geriatric expertise situated at the emergency department, the hospital ward staff, and a multi-professional team with a case manager in the municipal care services for older people. Implementation was evaluated between September 2008 and May 2010 with observations of work practices, stakeholder interviews, and document analysis according to a modified version of The Conceptual Framework for Implementation Fidelity.

Results

A total of 16 of the 18 intervention components were to a great extent delivered as planned, while some new components were added to the model. No changes in the frequency or duration of the 18 components were observed, but the dose of the added components varied over time. Changes in fidelity were caused in a complex, interrelated fashion by all the moderating factors in the framework, i.e., context, staff and participant responsiveness, facilitation, recruitment, and complexity.

Discussion

The Conceptual Framework for Implementation Fidelity was empirically useful and included comprehensive measures of factors affecting fidelity. Future studies should focus on developing the framework with regard to how to investigate relationships between the moderating factors and fidelity over time.

Trial registration

ClinicalTrials.gov, NCT01260493.

Background

Due to fragmentation of care, continuity of care is often limited in the care provided to frail older people. Further, frail older people are not always enabled to become involved in their own care. Therefore, we developed the Health and Welfare Information Portal (ZWIP), a shared Electronic Health Record combined with a communication tool for community-dwelling frail older people and primary care professionals. This article describes the process evaluation of its implementation, and aims to establish (1) the outcomes of the implementation process, (2) which implementation strategies and barriers and facilitators contributed to these outcomes, and (3) how its future implementation could be improved.

Methods

Mixed methods study, consisting of (1) a survey among professionals (n = 118) and monitoring the use of the ZWIP by frail older people and professionals, followed by (2) semi-structured interviews with purposively selected professionals (n = 12).

Results

290 frail older people and 169 professionals participated in the ZWIP. At the end of the implementation period, 55% of frail older people and informal caregivers, and 84% of professionals had logged on to their ZWIP at least once. For professionals, the exposure to the implementation strategies was generally as planned, they considered the interprofessional educational program and the helpdesk very important strategies. However, frail older people’s exposure to the implementation strategies was less than intended. Facilitators for the ZWIP were the perceived need to enhance interprofessional collaboration and the ZWIP application being user-friendly. Barriers included the low computer-literacy of frail older people, a preference for personal communication and limited use of the ZWIP by other professionals and frail older people. Interviewees recommended using the ZWIP for other target populations as well and adding further strategies that may help frail older people to feel more comfortable with computers and the ZWIP.

Conclusions

This study describes the implementation process of an innovative e-health intervention for community-dwelling frail older people, informal caregivers and primary care professionals. As e-health is an important medium for overcoming fragmentation of healthcare and facilitating patient involvement, but its adoption in everyday practice remains a challenge, the positive results of this implementation are promising.

The ‘Learning Organisation’ is a concept first described by Peter Senge as an organisation where people continuously learn and enhance their capabilities to create. It consists of five main disciplines: team learning, shared vision, mental models, personal mastery and systems thinking. These disciplines are dynamic and interact with each other. System thinking is the cornerstone of a true learning organisation and is described as the discipline used to implement the disciplines. In a learning organisation, health care education aims to educate its members with up to date knowledge to produce competent and safe personnel, who can promote quality in health care services. In addition, there are some educational concepts and theoretical models, which are of relevance to the learning organisation, and can provide a framework for managerial decisions. The stages required to achieve the principles of a learning organisation will be described in detail. Moreover, in a proper culture which supports the learning organisation, members continuously learn to improve the environment and never remain passive recipients.

Introduction

The Netherlands Organisation of Health Research and Development (ZonMw) has launched the ambitious National Care for the Elderly Programme to improve care and support for frail elderly persons. This four years programme (2008–2011) is initiated by the Ministry of Health, Welfare and Sport. The budget is 80 million euro.

Description

The programme consists of three steps. First, regional networks were formed consisting of all parties that can contribute to the organisation of care and support for frail elderly persons. Second, innovative experiments were formed within these networks. These experiments focus on a reorganisation and integration of care and support and are formally evaluated. They should lead to added value for elderly people, in terms of greater self-reliance, better retention of function, and reduced care use and treatment burden. The third step is dissemination and implementation of knowledge.

Conclusions

Eight networks are formed and continue to grow. These networks developed 13 experiments on the following topics: screening of frailty, reactivation after hospitalisation, improvement of primary care, integrated care, and new information systems. More experiments will follow.

Discussion

We aim for better integrated care and added value for frail elderly persons through formation of networks and experiments. Whether this approach works is still to be tested.

Background

To improve health in the population, public health interventions must be successfully implemented within organisations, requiring behaviour change in health service providers as well as in the target population group. Such behavioural change is seldom easily achieved. The purpose of this study was to examine the outcomes of a child health promotion programme (The Salut Programme) on professionals’ self-reported health promotion practices, and to investigate perceived facilitators and barriers for programme implementation.

Methods

A before-and-after design was used to measure programme outcomes, and qualitative data on implementation facilitators and barriers were collected on two occasions during the implementation process. The sample included professionals in antenatal care, child health care, dental services and open pre-schools (n=144 pre-implementation) in 13 out of 15 municipalities in a Swedish county. Response rates ranged between 81% and 96% at the four measurement points.

Results

Self-reported health promotion practices and collaboration were improved in all sectors at follow up. Significant changes included: 1) an increase in the extent to which midwives in antenatal care raised issues related to men’s violence against women, 2) an increase in the extent to which several lifestyle topics were raised with parents/clients in child health care and dental services, 3) an increased use of motivational interviewing (MI) and separate ‘fathers visits’ in child health care 4) improvements in the supply of healthy snacks and beverages in open pre-schools and 5) increased collaboration between sectors. Main facilitators for programme implementation included cross-sectoral collaboration and sector-specific work manuals/questionnaires for use as support in everyday practice. Main barriers included high workload, and shortage of time and staff.

Conclusion

This multisectoral programme for health promotion, based on sector-specific intervention packages developed and tested by end users, and introduced via interactive multisectoral seminars, shows potential for improving health promotion practices and collaboration across sectors. Consideration of the key facilitators and barriers for programme implementation as highlighted in this study can inform future improvement efforts.

Background

This paper outlines the principal characteristics of a learning organisation and the organisational features that define it. It then compares these features with the organisational conditions that currently obtain, or are being created, within the British NHS. The contradictory development of recent British health policy, resulting in the NHS becoming both more marketised and more bureaucratised has correspondingly ambiguous implications for attempts to implement a 'learning organisation' model.

Methods

Texts that define and debate the characteristics of a learning organisation were found by snowballing references from the founding learning organisation books and published papers, and then by searching a database specifically devised for a literature review on organisational structures and processes in health care. COPAC and ABI-Info databases for subsequent peer-reviewed publications that also appeared relevant to the present study were searched.

Results

The outcomes of the above search are summarised and mapped onto the current constituent organisations of the NHS to identify the extent to which they achieve or approximate to a learning organisation status.

Conclusion

Because of the complexity of the NHS and the contradictory processes of marketisation and bureaucratisation characterising it, it cannot, as a whole system, become a learning organisation. However, it is possible that its constituent organisations may achieve this status to varying degrees. Constraints upon NHS managers to speak their minds freely place an ultimate limit on learning organisation development. This limitation suggests that current British health service policy encourages organisational learning-but not too openly and not too much.

Background

Little research attention has been given to attempts to implement organisational initiatives to improve quality of care for mental health care, where there is a high level of indeterminacy and clinical judgements are often contestable. This paper explores recent efforts made at an organisational level in England to improve the quality of primary care for people with mental health problems through the new institutional processes of 'clinical governance'.

Methods

Framework analysis, based on the Normalisation Process Model (NPM), of attempts over a five year period to develop clinical governance for primary mental health services in Primary Care Trusts (PCTs). The data come from a longitudinal qualitative multiple case-study approach in a purposive sample of 12 PCTs, chosen to reflect a maximum variety of organisational contexts for mental health care provision.

Results

The constant change within the English NHS provided a difficult context in which to attempt to implement 'clinical governance' or, indeed, to reconstruct primary mental health care. In the absence of clear evidence or direct guidance about what 'primary mental health care' should be, and a lack of actors with the power or skills to set about realising it, the actors in 'clinical governance' had little shared knowledge or understanding of their role in improving the quality of mental health care. There was a lack of ownership of 'mental health' as an integral, normalised part of primary care.

Conclusion

Despite some achievements in regard to monitoring and standardisation of prescribing practice, mental health care in primary care seems to have so far largely eluded the gaze of 'clinical governance'. Clinical governance in English primary mental health care has not yet become normalised. We make some policy recommendations which we consider would assist in the process normalisation and suggest other contexts to which our findings might apply.

Introduction

Quality of care provided to people with chronic conditions does not often fulfil standards of care in Denmark and in other countries. Inadequate organisation of healthcare systems has been identified as one of the most important causes for observed performance inadequacies, and providing integrated healthcare has been identified as an important organisational challenge for healthcare systems. Three entities—Bispebjerg University Hospital, the City of Copenhagen, and the GPs in Copenhagen—collaborated on a quality improvement project focusing on integration and implementation of rehabilitation programmes in four conditions.

Description of care practice

Four multidisciplinary rehabilitation intervention programmes, one for each chronic condition: chronic obstructive pulmonary disease, type 2 diabetes, chronic heart failure, and falls in elderly people were developed and implemented during the project period. The chronic care model was used as a framework for support of implementing and integration of the four rehabilitation programmes.

Conclusion and discussion

The chronic care model provided support for implementing rehabilitation programmes for four chronic conditions in Bispebjerg University Hospital, the City of Copenhagen, and GPs' offices. New management practices were developed, known practices were improved to support integration, and known practices were used for implementation purposes. Several barriers to integrated care were identified.

Purpose

Present the results of an exploratory study which aimed to identify the attributes of relational continuity as conceived by the actors involved in the organization of services to frail older people.

Theory

The lengthening of the duration of life with autonomy loss warrants a transformation of the response to the needs of older people. The organization of services must evolve from a hospital-centered model to a residence-centered model better adapted to long-term care. This refocus on residential care provokes a multiplication of service providers which must be coordinated to ensure continuity of care [1]. Amongst the three forms of continuity (informational, management and relational) [2], relational continuity appears as the least documented and most difficult to measure.

Methods

Twenty-seven interviews with practitioners, managers, family caregivers and users were conducted and analysed using a content analysis approach.

Results and conclusions

While the family caregivers and users stressed the psycho-affective nature of the care relationship, the practitioners viewed it as a means to ensure the adequacy of services. From the user's viewpoint, the relationship is not the responsibility of one professional, but of a collective effort that may carry his voice across the services organization.

Research question

We are looking at the process of structuring an integrated care system as an innovative process that swings back and forth between the diversity of the actors involved, local aspirations and national and regional regulations. We believe that innovation is enriched by the variety of the actors involved, but may also be blocked or disrupted by that diversity. Our research aims to add to other research, which, when questioning these integrated systems, analyses how the actors involved deal with diversity without really questioning it.

Case study

The empirical basis of the paper is provided by case study analysis. The studied integrated care system is a French healthcare network that brings together healthcare professionals and various organisations in order to improve the way in which interventions are coordinated and formalised, in order to promote better detection and diagnosis procedures and the implementation of a care protocol. We consider this case as instrumental in developing theoretical proposals for structuring an integrated care system in light of the diversity of the actors involved.

Results and discussion

We are proposing a model for structuring an integrated care system in light of the enacted diversity of the actors involved. This model is based on three factors: the diversity enacted by the leaders, three stances for considering the contribution made by diversity in the structuring process and the specific leading role played by those in charge of the structuring process. Through this process, they determined how the actors involved in the project were differentiated, and on what basis those actors were involved. By mobilising enacted diversity, the leaders are seeking to channel the emergence of a network in light of their own representation of that network. This model adds to published research on the structuring of integrated care systems.

Introduction

The PRISMA integration model is a promising method to implement integration in health and social services for elderly people. The PRISMA France study aims to investigate the implementation of this model, which relies on the establishment of advisory boards at institutional, organisational and professional levels of decision-making, in France. These boards are guided by whole systems thinking and function in a joined-up, co-ordinated manner.

Method

A qualitative approach was adopted to study the model's implementation. Analyses were based on semi-structured interviews with actors of all levels of decision-making, observations of advisory board meetings and administrative documentations. Validity was insured by triangulation methods and content saturation.

Results

Our analyses revealed the complexity, instability and fragmentation of the institutional governance of publics policies for elderly people. The ‘path dependence’ to the Bismarckian system and the incomplete reforms of gerontological policies generate a cohabitation of three concurrent policies (national, regional and local) and a juxtaposition of two institutional systems (health and social care policy and social welfare). In such a context, no institution possesses sufficient authority to determine gerontological policy.

Conclusion

In the light of these analyse, the particularly complex and time-consuming implementation of the PRISMA model in France can be better understood.

Abstract

Over the past decade, policy makers in developed countries have begun to pay increasing attention to reform of the long-term care system for the frail elderly and younger people with disabilities. A continuum of strategies have generated interest, including integrated systems of care with agency/professionally managed service packages on the one end, and programs offering cash benefits along with the flexibility to decide how to best use these funds to meet individual needs and preferences, on the other. The latter approach, known as “consumer-directed care,” is found in various forms and degrees in Europe and North America. Primarily organised around the provision of home and community care, consumer-directed services are aimed at empowering clients and family carers, giving them major control over the what, who and when of needed care. Consumer-directed care appears to be the antithesis of integrated care. However, it actually holds important lessons and implications for the latter. This policy paper explores the rationale and models of consumer-directed services at home, reviews developments, designs and outcomes of programs in the Austria, Germany, the Netherlands, and the US. It also discusses how this experience could be helpful in shaping better and more responsive integrated models of care for vulnerable long term care populations.

Background

Swedish health care is decentralised to regional and local providers. Through the Health Act from 1992 counties and communities have mutual responsibilities for medical rehabilitation. However, the limits of responsibilities are not well described in the law, and have to be worked out in regional and local agreements. Negotiations have often been protracted and in addition, parallel organisations with similar competences have been established in several regions increasing the total costs.

The project

In Lidköping a three years project was launched in 2005 with a common organisation for medical rehabilitation including the responsibilities for primary and community care. Technically the municipality has taken the full responsibility and all personnel is transferred to the community as employer with appropriate financial support from the county. A total of 50 persons with different professions are involved in the joint organisation covering all kinds of medical rehabilitation including technical aid.

Assessment

The project has been assessed during the ongoing process with qualitative and quantitative methods. Common premises and documentation system, one single budget, in addition to less doubling of activities has decreased the costs and improved the service level. In interviews the common view has been that problems related to division of responsibilities between providers have been reduced. The project is still characterised by a pioneer spirit, and several details need to be worked out. The positive attitude seems to be in part supported by extensive involvement by the personnel in the planning procedure, and a whole-hearted support from the political and administrative management.

The future

A summary assessment is planned for spring 2008. The expectations are that this project will be turned into an exemplary permanent organisation of integrated care for medical rehabilitation.

Background

Organisation of acute care services for people living in residential aged care facilities (RACF) is a complex area of health policy. For people living in RACF, the emergency department is often used to provide acute care; needs of RACF residents, however, are not always well met. Alternative models of delivering care must be acceptable to a variety of stakeholders; however, little is known about the values and preferences that people attach to aspects of how and where care is delivered.

Methods/design

The PROSpER Study examines people's preferences for the organisation of acute healthcare services for older people in RACF. The authors aim to (1) determine which factors influence preferences of residents, carers and providers for how and where acute care is delivered and (2) determine the relative importance of these factors and the acceptable trade-offs between them. Qualitative and quantitative methods will be used. One-on-one interviews will be conducted with RACF residents, their families, staff of RACF and emergency department staff. A discrete choice study will then be designed to quantitatively assess preferences for alternative models of care delivery. Approximately 600 respondents from three respondent groups will be surveyed: older people living in RACF, family members of aged care residents and staff of RACF. A mixed logit model will be used; results will be expressed as parameter estimates (β) and odds of choosing one option over an alternative. Trade-offs between attributes will also be calculated.

Ethics and dissemination

The PROSpER Study has been approved by the University of Sydney, Human Research Ethics Committee (Protocol numbers 10653 and 14382) and Royal Perth Hospital Ethics Committee (reference 2009/045). Results will be published in peer-reviewed scientific journals and via conference presentations; a newsletter will also be provided to study participants. A stakeholder roundtable will also be held to discuss the results.

Article summary

Article focus

To assess the preferences of older people living in residential aged care facilities (RACF), their families and staff in relation to the provision of acute health care services for older Australians in RACF.

To determine what factors most influence the preferences of these stakeholders for how and where acute care is delivered.

To determine the relative importance of these factors and the trade-offs between them.

Key messages

The organisation of acute healthcare services for older people living in RACF is a complex area of health policy involving considerations of clinical, economic, ethical and legal issues. For older people living in RACF, the emergency department is frequently used to provide acute care services. While emergency department generally works well if people have a short-term problem that can be resolved with a one-off intervention, the needs of people from RACF, often with chronic disease, multiple complex health problems and frailty are less well met.

Alternative models of delivering acute care need to be acceptable to the residents, family and RACF staff; however, little is known about the values and preferences that people attach to aspects of how and where care is delivered or the trade-offs between various aspects of care that people are willing to make.

This study will use best practice qualitative and quantitative methods for preference elicitation (a discrete choice experiment) to assess the preferences and acceptable trade-offs of RACF residents, their families and staff for alternative healthcare delivery models.

Strengths and limitations of this study

The strengths of the study are that it is the first study to use discrete choice methods to examine preferences for alternative models of acute healthcare service delivery in multiple stakeholder groups: residents of RACF, their families and RACF staff.

The limitation is that it is conducted in one country, Australia, and thus its generalisability may be limited by the prevailing model of acute healthcare service delivery.

Introduction

Within the UK health and social care policy is placing an increasing emphasis on improving the quality of care for older people in care homes through integrated working between health and social care services. This study aims to clarify the research available on integrated working and evaluate its impact on older people in order to devise a typology for informing future service development.

Theory

Kodner and Spreeuwenberg [1] argue that patient/person centred integrated working between health and social care should include methods and models which involve the different levels of organisation, management, funding and clinical care within and between them.

Methods

Phase one included a systematic review to evaluate interventions utilising integrated working between care home staff and health care practitioners, and a survey to describe care homes’ experiences of integrated working. Phase one will inform phase two; a case study evaluating six different approaches to integrated working currently in use in three different areas of England.

Results and conclusions

The review found evidence of integrated working between health care and care homes at the patient level of care, but minimal evidence of models that extended beyond this level. Findings from the survey, currently in progress, will also be presented.

Discussion

The discussion will provide an overview of the challenges and issues surrounding integrated working.

Purpose

To enable an understanding of the complexities involved in evaluating and improving the partnerships between organisations involved in integrated working.

Theory

Network organisations provide a unique challenge to understanding and evaluating the processes and mechanisms through which organisations integrate. Through integrating research into this interface we propose a methodology for evaluation.

Methods

A Grounded Theory study of partnership working in network organisations, with data analysis to build a theoretical model of the way that partnership works in complex organisational situations.

Results and conclusions

Integrating care involves working across multiple organisations, creating complex environments for assessment and evaluation. We show that what happens in the ‘spaces’ between organisations involved in complex partnership arrangements is crucial and that current methods of partnership evaluation are inadequate for complex partnership situations, such as network organisations. Our model for integrating research into these interfaces between organisations involved in care enables these complexities to be better understood with the potential for real improvements in complex integrated care situations. In order to achieve this it is important that a theoretically-rooted, context-specific evaluative tool can be developed. This paper presents the Model of Network Partnership which the authors believe is a crucial stage in the process of development of such a tool with the potential to promote genuine improvements in integrated working.

Objectives

To understand organisational technology adoption (initiation, adoption decision, implementation) by looking at the different types of innovation knowledge used during this process.

Design

Qualitative, multisite, comparative case study design.

Setting

One primary care and 11 acute care organisations (trusts) across all health regions in England in the context of infection prevention and control.

Participants and data analysis

121 semistructured individual and group interviews with 109 informants, involving clinical and non-clinical staff from all organisational levels and various professional groups. Documentary evidence and field notes were also used. 38 technology adoption processes were analysed using an integrated approach combining inductive and deductive reasoning.

Main findings

Those involved in the process variably accessed three types of innovation knowledge: ‘awareness’ (information that an innovation exists), ‘principles’ (information about an innovation's functioning principles) and ‘how-to’ (information required to use an innovation properly at individual and organisational levels). Centralised (national, government-led) and local sources were used to obtain this knowledge. Localised professional networks were preferred sources for all three types of knowledge. Professional backgrounds influenced an asymmetric attention to different types of innovation knowledge. When less attention was given to ‘how-to’ compared with ‘principles’ knowledge at the early stages of the process, this contributed to 12 cases of incomplete implementation or discontinuance after initial adoption.

Conclusions

Potential adopters and change agents often overlooked or undervalued ‘how-to’ knowledge. Balancing ‘principles’ and ‘how-to’ knowledge early in the innovation process enhanced successful technology adoption and implementation by considering efficacy as well as strategic, structural and cultural fit with the organisation's context. This learning is critical given the policy emphasis for health organisations to be innovation-ready.

Article summary

Article focus

Despite policy support and the development of a dedicated evidence dissemination infrastructure in the NHS, why is technology adoption and implementation still a challenge?

We need to understand better how the innovation process unfolds in organisations to build on what we know about individual behaviours. In particular, how the use of different types of knowledge about an innovation impacts its adoption and implementation.

Key messages

In our study, centralised dissemination of evidence had minimal to moderate impact on organisational innovation adoption decisions. Practice-based, peer-mediated and local dissemination systems were perceived more relevant.

In contrast to technology adoption by individuals, organisational adoption required a wider multifaceted conceptualisation of ‘how-to’ knowledge in line with the more complex dynamics in organisations. When ‘how-to’ knowledge was undervalued and considered late, important strategic, structural and cultural elements of the trust's context were overlooked. This had negative implications for technology adoption and implementation.

Professional backgrounds of those involved in the process influenced the types of innovation knowledge considered, which had implications for implementation. The involvement of diverse professionals in decision-making improves the chances of successful implementation through a balanced consideration of the strength of scientific evidence and practical application.

Strengths and limitations of this study

The scale of the study, its real time and longitudinal nature provide a rich data set. Our study is theory driven and comprises multisite comparative case studies, which enhance the generalisability of findings beyond the context of the studied trusts.

We explicitly studied cases of non-adoption and discontinuation after initial adoption to provide important learning often missing from innovation diffusion research.

On limitations, we were not able to follow implementation past the end of August 2010 and therefore do not have information on routinised use of the implemented technologies.

Introduction

A project of vocational rehabilitation was studied in Sweden between 1999 and 2002. The project included four public organisations: the social insurance office, the local health services, the municipal social service and the office of the state employment service. The aim of this paper was to analyse perceived barriers in the development of inter-organisational integration.

Theory

Theories of inter-professional and inter-organisational integration, and theories on organisational change.

Methods

In total, 51 semi-structured interviews and 14 focus group discussions were performed with actors within the project between 1999 and 2002. A thematic approach was used for the analysis of the data.

Results

Three different main themes of barriers emerged from the data: A Uncertainty, B Prioritising own organisation and C Lack of communication. The themes are interconnected in an intricate web and hence not mutually exclusive.

Conclusions and discussion

The barriers found are all related partly to organisational change in general and partly to the specific development of organisational integration. Prioritising of own organisation led to flaws in communication, which in turn led to a high degree of uncertainty within the project. This can be seen as a circular relationship, since uncertainty might increase focus on own organisation and lack of communication.

A way to overcome these barriers would be to take the needs of the clients as a point of departure in the development of joint services and to also involve them in the development of inter-organisational integration.

Background

Although teamwork is known to optimise good health care, organisational arrangements and funding models can foster, discourage, or preclude functional teamworking. Despite a new, enhanced population-based funding system for primary care in New Zealand, bringing new opportunities for more collaborative practice, fully implemented healthcare teamwork remains elusive.

Aim

To explore perceptions of interprofessional relationships, teamwork, and collaborative patient care in New Zealand primary care practice.

Design of study

Qualitative.

Setting

Eighteen nurses and doctors working in primary care, Wellington, New Zealand.

Method

Data were collected using in-depth interviews with individual nurses and doctors working in primary care settings. Perceptions of, and attitudes about, interprofessional relationships, teamwork, and collaborative patient care were explored, using an interactive process of content analysis and principles of naturalistic enquiry.

Results

Nurses and doctors working in New Zealand primary care perceive funding models that include fee-for-service, task-based components as strongly discouraging collaborative patient care. In contrast, teamwork was seen to be promoted when health services, not individual practitioners, were bulk-funded for capitated healthcare provision. In well-organised practices, where priority was placed on uninterrupted time for meetings, open communication, and interprofessional respect, good teamwork was more often observed. Salaried practices, where doctors and nurses alike were employees, were considered by some interviewees to be particularly supportive of good teamwork. Few interviewees had received, or knew of, any training to work in teams.

Conclusion

Health system, funding, and organisational factors still act as significant barriers to the successful implementation of, and training for, effective teamwork in New Zealand primary care settings, despite new opportunities for more collaborative ways of working.

Headache disorders are a major public-health priority, and there is pressing need for effective solutions to them. Better health care for headache—and ready access to it—are central to these solutions; therefore, the organisation of headache-related services within the health systems of Europe becomes an important focus. These recommendations are the result of collaboration between the European Headache Federation and Lifting The Burden: the Global Campaign against Headache. The process of development included wide consultation. To meet the very high level of need for headache care both effectively and efficiently, the recommendations formulate a basic three-level model of health-care organisation rationally spread across primary and secondary health-care sectors, taking account of the different skills and expertise in these sectors. They recognise that health services are differently structured in countries throughout Europe, and not always adequately resourced. Therefore, they aim to be adaptable to suit these differences. They are set out in five sections: needs assessment, description of the model, adaptation, standards and educational implications.

Headache disorders are a major public-health priority, and there is pressing need for effective solutions to them. Better health care for headache—and ready access to it—are central to these solutions; therefore, the organisation of headache-related services within the health systems of Europe becomes an important focus. These recommendations are the result of collaboration between the European Headache Federation and Lifting The Burden: the Global Campaign against Headache. The process of development included wide consultation. To meet the very high level of need for headache care both effectively and efficiently, the recommendations formulate a basic three-level model of health-care organisation rationally spread across primary and secondary health-care sectors, taking account of the different skills and expertise in these sectors. They recognise that health services are differently structured in countries throughout Europe, and not always adequately resourced. Therefore, they aim to be adaptable to suit these differences. They are set out in five sections: needs assessment, description of the model, adaptation, standards and educational implications.