25 Nov Best Practices in Healthcare Integration
BEST PRACTICES IN HEALTHCARE INTEGRATION
Authors: John Kueven (USA, Co-chair), Hwee Sin Chong (Australia), Urszula Szybowicz (Poland), Shrikant Peters (South Africa). Reviewed by Tavy Alford (IHF Intern).
The healthcare industry is inherently complex. The variety of services provided, diversity of the workforce, uniqueness of each consumer, range of professionals, and dependency of healthcare providers on each other creates an environment that can be difficult to navigate for patients and challenging for workers to coordinate care.
Integration was defined through various countries’ perspectives in our first article, which can be consulted here. Now, to understand which parts of the healthcare system would most benefit from integration, it is important to understand the healthcare journey through the patient’s, or consumer’s, perspective. Patients and their advocates must seek care from various sectors ranging from primary healthcare to specialised sub-acute, rehabilitation and acute care in hospital and to non-hospital settings, across the continuum of prevention to end stage care. An integrated and well-coordinated care pathway for patients is essential to achieve the best health outcomes possible, while reducing waste in the healthcare system. When the needs of patients are placed at the centre, there is also improved satisfaction1.
The need to integrate health systems is called ‘comprehensive primary health care’ a term agreed upon at the World Health Organization (WHO) Alma Ata conference in 1978. To achieve this level of integration, healthcare policy must be underpinned by the three principles of participation, equity and intersectoral collaboration2.
A 2015 report by the World Health Organization3 presents five different strategic directions considered to improve health care integration and co-ordination, based on evidence and examples. These areas are: empowering and engaging people; strengthening governance and accountability; reorienting the model of care; co-ordinating services; and creating an enabling environment.
Empowering and engaging patients and communities helps inform what type of services should be offered, as well as where, how, and to whom, and at any point in the care continuum. Thus, if the focal point for improvement is the delivery of care to the individual patient, then services should be coordinated around the patient and the needs of their family. Care coordination for the individual is not only about coordination across service providers, but it is also about coordinating care over time, through improved information flows and maintaining relationships with providers. Multidisciplinary teams also need to be coordinated in clinical processes and care outcomes at an individual, community and population level. This procedure involves identifying team members, defining their roles and functions, defining shared goals and targets, and a systematically evaluating achieved targets4.
Although integration of services can be both advantageous and economically beneficial to the patient and the provider, it may not always be possible given the structure and funding models of health services. For example, in Australia it has been recognised that a split in federal and state government funding and responsibilities are central to the challenge of coordinating patient care5.In these circumstances, seeking to co-ordinate services and collaborate with providers as much as possible, or assisting the patient through navigation interventions can overcome several barriers and seems to be effective in enhancing the abilities of poor and vulnerable populations to access healthcare4.
In seeking to drive integration in healthcare, many leaders struggle to balance the needs of patients and staff, while organizing services in a way that matters. In this article, we will explore integration from a variety of perspectives including:
- The integration and coordination of patient care
- Operational integration of healthcare, and
- Leveraging technology to improve integration.
HORIZONTAL VS. VERTICAL INTEGRATION IN HEALTHCARE
Horizontal integration in healthcare involves multi-disciplinary teamwork between health services, social services, and other healthcare providers6. It is in the domain of social sciences, and interagency collaborators learn, inquire and innovate together. It involves cross-organisational planning which leads to a synchronism of effort that creates an environment for good health outcomes2.
Vertical integration focuses on joining together primary, community and hospital services6. In developing countries, vertical programs divert human and financial resources from already resource-constrained health systems. It involves focusing on patient pathways to treat medical conditions, connecting generalists and specialists, whereas horizontal integration involves broad based collaboration to improve overall health. Comprehensive integration includes a good balance of both2.
Vertical integration is based on coordinating complementing healthcare services, thus fulfilling patients’ needs on various levels. Vertical integration can happen between hospital and physicians, between insurers and hospitals, between hospitals and suppliers of medicines, etc. Horizontal integration is based on partnering health services which provide health services to clients on the same or similar level.
Vertical integration allows better control over the supply chain, providing four key advantages: specialisation, quality assurance, access to new markets, and stability. Providers who control more of their supply chain have more ability to specialise and distinguish themselves from others within the healthcare industry through a unique “value proposition and brand message that resonates” with patients. Also, it allows providers to closely monitor and enforce quality standards. Partnerships between hospitals, insurance agencies, large corporations, or tech firms can open doors to new markets, creating access to a brand or business that may have been unavailable before. Finally, vertical integration can eliminate unpredictability and create the stability needed to invest for the future7.
Some drawbacks of vertical integration may include high capital requirements to establish a fully integrated business model, unforeseen barriers to entry, confusion for patients, and the inevitable complexity of managing a new system7.
Healthcare leaders must constantly assert a need for a meaningful balance between the vertical and horizontal dimensions, in pursuit of comprehensive primary healthcare. Further, there must be mechanisms that enable vertical and horizontal activities to helpfully mould each other through ongoing whole-system inquiries and action.
Comprehensive integration includes a good balance of both vertical and horizontal integration. A good example of comprehensive healthcare system, the treatment of severe mental illness, requires vertical integration for generalist and specialist medical practitioners to work together in the best way, whereas horizontal integration is needed to create environments that will develop confident creative citizens.
The term operational integration, for this article, refers to the action or process of creating a consistent and organized approach to how healthcare organizations are run. It includes, but is not limited to, reducing silos across many departments, setting clinical and operational standards across multiple locations, driving an environment where team members work together for a common purpose, and balancing the various needs of consumers. The challenge of truly integrating operations in healthcare stems from the inherent complexity within the industry. This complexity exists for both consumers and leaders. For consumers, healthcare is complex for many reasons, including difficult terminology, lack of coordination in clinical treatment, business functions not being consumer centric, and costs that are often unknown and impossible to interpret. For leaders, the operations within healthcare are complicated by the increasing complexity of treatment, an ever-growing list of regulations, and a struggle to find balance between cost, quality, and the consumer’s experience.
Given the complexity of healthcare, how do we achieve integration? Many organizations make the mistake of adding complexity to address complexity. Layering on committees, policies, procedures, leadership levels to react to complexity is common. However, these actions often move organization away from integration, not towards it. Complexity must be met with simplicity. Operational integration must stem from a common set of principles that create a framework for how an organization is run, referred to in this article as an operating model. An operating model must be established by an organization to drive integration between departments, engage in a partnership with patients, and to bring together disparate processes. According to an article in Becker’s Review, key tenets of this operating model must include:
- Imparting directional vision rather than set detailed, inflexible strategic plans.
- Favouring fluid decision-making over non-flexible guidelines for organizational decisions. Don’t be afraid to improve and experiment.
- Simplify organizational structure and processes. Remove structural and procedural complexity so employees can exercise personal judgment.
- Institutionalize leadership throughout the organization. Avoid relying only on top-down management.
- Embrace collaboration among employees, units, and entities outside the organization.
These tenets must be delivered by leaders seeking to influence beyond their authority. According to Erica Hersh, a writer for the Harvard School of Public Health, leaders must function in multiple directions including:
- Leading down to your team
- Leading up, offering perspective and guidance to help your boss reach decisions
- Leading across your organization to link and leverage different organizational silos
- Leading beyond, working with stakeholders outside your organization
Understanding the key tenets of an operating model and how healthcare leaders must lead is the beginning of creating operational integration. An organization’s operating model must be a tangible framework that creates this integration through repeatable processes and expectations. In the United States, the Malcolm Baldrige criteria for performance excellence gives leaders a readymade operating model, a framework for practicing good business. The Baldrige framework is not the only potential operating model, but it does give a best practice, as hospitals that embrace the Baldrige framework in the United States outperform their peer hospitals. According to Foster and colleagues, Baldrige hospitals showed they are “significantly more likely than their peers to win a 100 Top Hospitals national award. Baldrige winning hospitals were significantly more likely than their peers to display faster five-year performance improvement. Baldrige hospitals, as a group, were about 83 percent more likely than non-Baldrige hospitals to be awarded a 100 Top Hospitals national award for excellence in balanced organization-wide performance”8. The results of an organization utilizing an operating model to systematically improve integration is clear. These organizations outperform their peers over a sustained period. The successful healthcare organization will take a step back from the complex environment and utilize an operating model to create simplicity for both its team members and its consumers.
Nowadays, technology is increasingly becoming an essential part of patient care. Leverage in technology translates to increased efficiency, quality improvement, enhanced customer satisfaction, and cost containment in the delivery of care. In the last two decades, healthcare has encountered the following technological advancements; electronic health records (EHR), telemedicine, mHealth, portal technology, self-service kiosks, sensors and wearable technology, wireless communication, and real-time locating services. Going forward, more innovations like drone-delivery, mind-reading wrist bands, and pocket ultra-sound devices are emerging futuristic health technological solutions which we cannot ignore. Regardless, only some of these developments have been fully adopted into some healthcare systems. What could be the reason for this slow to no integration? Below are some possible answers:
1 – Different Health systems; different needs.
Every hospital has its unique needs on which to base priorities and policies. Health systems want to invest in ‘healthtech’ which meets their needs 100%; but are these new technologies 100% guaranteed to achieve this as compared to traditional methods of healthcare delivery? Adopting a new technology requires a multidisciplinary approach, an assured return on investment, and evidence of better patient outcomes. Otherwise, it’s like flushing the money down the drain. The needs of a hospital in a developed country are different from those of a developing one; hence, these technologies should be tailored to appropriately suit the needs of the respective end-users.
2 – Rapid evolution of technology
Medical technology is very expensive to acquire and maintain. Every now and then, there are new developments and advanced features for health devices, such as surgical equipment, which render the old version obsolete. Moreover, it is even worse when the health provider demands to have the latest device in the market for use, leaving a hospital with a dilemma about whether to purchase, lease or abstain from buying said equipment on grounds of cost or sustainability. While a focus on treatment methodology is best, an investment in better and latest technology can give an organization a competitive edge. The question is how to keep up with dynamic technologies.
3 – User incompetence
Technology can fuel both satisfaction or frustration. For example, it is already challenging enough for people to engage in a Zoom meeting because some cannot switch off the microphone when they are not speaking, or their camera when they are in the toilet. Similarly, if a health provider or a client lacks the required knowledge and skills regarding a particular health technology, then there is no value in using it. For instance, effective adoption of EHR calls for a huge investment in staff training to ensure accurate data entry and adherence to medical-legal provisions. Without training, implementation may be met with resistance and eventual failure.
In conclusion, to provide the best value for the client’s money, health system leaders are looking to technology to enhance their processes and improve satisfaction and outcomes. Whilst this is can be effective, barriers which stand in the way of leveraging technology for maximum benefits need to be addressed. Additionally, the end-user needs and resources when developing technology integration strategies must be considered. Organizations must perform a cost-benefit analysis before investing in any technology for assured returns on investment and for guaranteed customer satisfaction.
MEASUREMENT OF SUCCESS
The measurement of success for an integrated system is a complex endeavour and must be multifaceted. There is no single metric that could encompass the effectiveness of integrated care for patients. Value must be considered and include cost, experience, and quality. Hospitals should set goals for performance in key quality metrics, ensure a standard way to listen to customers and measure their engagement, and these metrics should be benchmarked against best-in-class performance.
- nejm.org. 2021. What Is Patient-CenteredCare?. [online] Available at: <https://catalyst.nejm.org/doi/full/10.1056/CAT.17.0559> [Accessed 2 October 2021]
- Paul Thomas FRCGP MD, Geoffrey Meads PhD MSc MA, Ahmet Moustafa MA MSc RN, Irwin Nazareth FRCGP PhD, Kurt C Stange MD PhD, Gertrude Donnelly Hess MD. 2008. “Combined horizontal and vertical integration of care: a goal of practice-based commissioning.” Radcliffe Publishing
- World Health Organization. (2015).People-centred and integrated health services: an overview of the evidence: interim report. World Health Organization.
- Sarah Louart, Emmanuel Bonnet, Valéry Ridde, Is patient navigation a solution to the problem of “leaving no one behind”? A scoping review of evidence from low-income countries,Health Policy and Planning, Volume 36, Issue 1, February 2021, Pages 101–116, https://doi.org/10.1093/heapol/czaa093
- OECD (2015), OECD Reviews of Health Care Quality: Australia 2015: Raising Standards, OECD Reviews of Health Care Quality, OECD Publishing, Paris, https://doi.org/10.1787/9789264233836-en.
- Smith, Nick Goodwin and Judith. 2011. “The Evidence Base for Integrated Care.” https://www.kingsfund.org.uk/audio-video/evidence-base-integrated-care.
- Sutherland, Princess. 2019. Healthcare Industry the Rise of Vertical Integration. https://www.spencertom.com/author/princesssutherland/
- Foster, D. A., Chenoweth, J., & President, S. V. (2011). Comparison of Baldrige Award applicants and recipients with peer hospitals on a national balanced scorecard. Ann Arbor, MI: Center for Healthcare Improvement, Truven Health Analytics.