Healthcare networks and
integration barriers
Healthcare integration barriers viewed from a supply chain
perspective
Master thesis Tessel Ebbes
S2521598
t.ebbes@student.rug.nl Supervisors University of Groningen:
Prof. Dr. J.T. van der Vaart Dr. A.G. Regts-Walters
Supervisor UMCG/HartNet Noord-Nederland: Prof. Dr. M. Rienstra
University of Groningen Faculty of Economics and Business
MSc Supply Chain Management January 26th, 2020
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ABSTRACT
Purpose: The healthcare system is fragmented, and care is delivered to patients by multiple care providers. The integration of care is lacking, while this is really important when patients see different providers during their patient journey. In healthcare networks, stakeholders are collaborating and integrating care, and the use of networks is increasing worldwide. A lot is known about the benefits of integrated care, however, also problems arise when implementing integrative practices. This study aims to find the barriers when integrating care in a network setting, and does this by applying a supply chain perspective.
Method: The study is based on a single case study of a cardiology network in The Netherlands. Twelve semi-structured interviews were conducted with a total of thirteen cardiologists, managers, an outpatient employee and a general practitioner that are all involved in two of the network’s care pathways. Findings: Ten barriers were identified in five categories: operational barriers (misalignment of schedules, insufficient medical knowledge GPs), informational barriers (lack of post treatment feedback, lack of information sharing, lack of connection between IT systems), relational barriers (lack of alignment between individual organizations’ goals and network goals, lack of employee involvement), financial barriers (perceived non-adjusted payments, non-declining costs) and organizational barriers (non-facilitating type of legal entity). The financial barriers were the most mentioned barriers, followed by the informational barriers.
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TABLE OF CONTENTS
Healthcare networks and integration barriers ... 1
Abstract ... 2 Table of contents ... 3 Preface ... 4 1. Introduction ... 5 2. Theoretical background ... 6 2.1 Healthcare networks ... 6
2.2 Supply Chain Integration ... 7
2.3 Integrated care and networks ... 8
2.4 Barriers of integration... 8 3. Research design ... 9 3.1 Research setting ... 9 3.2 Data collection ... 11 3.3 Data analysis ... 12 4. Research context ... 12 4.1 Care pathways ... 12 5. Results ... 16 5.1 Case analysis ... 17 6. Discussion ... 24 6.1 Operational barriers ... 24 6.2 Informational barriers ... 24 6.3 Relational barriers ... 25 6.4 Financial barriers ... 25 6.5 Organizational barriers ... 25 7. Conclusion ... 26 References ... 27
Appendix A: Interview protocol ... 30
English version ... 30
Dutch version ... 32
Appendix B: Additional interview quotes ... 36
Informational barriers ... 36
Relational barriers ... 37
Financial barriers ... 38
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PREFACE
5
1. INTRODUCTION
Today, healthcare systems are dealing with multiple challenges, amongst which one important challenge is fragmentation of care (Brown et al., 2016; Curry & Ham, 2010; Vargas et al., 2015; World Health Organization, 2008). Fragmentation is “a state of differentiation without the integration that is required to achieve unity of effort” (Axelsson & Axelsson, 2006). It has adverse consequences for patients (Curry & Ham, 2010) and causes inefficiencies, such as double activities, compromised quality of care, higher costs (Dutch Ministry of Health Welfare and Sports, 2018; Kailasam, Guo, Maw Hsann, & Soong Yang, 2019; Tsai, Orav, & Jha, 2015; World Health Organization, 2008) and different quality levels of care (Ahgren & Nordgren, 2012; Tsai et al., 2015). Tsai et al. (2015) even found that care fragmentation has a higher risk of death for older patients needing complex care.
To counter these issues, integration of care is needed (Curry & Ham, 2010). Moreover, because many care providers together are involved in the patient journey, there is a need for integration of the services of different care providers (Axelsson & Axelsson, 2006). Worldwide, more healthcare networks are developed (Brown et al., 2016). These networks consist of multiple independent healthcare organizations that collaborate (Willem & Gemmel, 2013), and can be used to integrate the care provision of the different care providers that are involved (Brown et al., 2016). However, it is known that implementation of collaboration is a real managerial challenge and that many inter-organizational collaborations fail (Auschra, 2018).
Additionally, there are some inhibiting factors of integrated care in inter-organizational settings. A literature review of Auschra (2018) described twenty types of integration barriers divided over six levels: administrative/regulative (e.g. regulations, national borders), funding (e.g. lack of organizational resources and external funding), inter-organizational (e.g. lack of leadership and coordination, power imbalances and conflicts), organizational (e.g. cultural distance, former collaboration experience), service delivery (e.g. lack of trust, resistance to change), and clinical (e.g. confidentiality issues). This shows that integrating care in inter-organizational settings is not as easy as it may seem.
In supply chain literature, many scholars have addressed integration, mainly in relationship with performance (Pagell, 2004). However, also in supply chains inhibiting factors of integration have been explored, being, amongst others, lack of consensus on strategy, lack of top management support, lack of communication between managers in different functions, and a mismatch between flow of work and flow of information (Pagell, 2004). Previous research has shown that an operational view on healthcare can create valuable knowledge, and that also internal hospital integration is a challenge (Drupsteen, van der Vaart, & Van Donk, 2016). Five integration barriers were found for integrative planning in hospitals: performance management, process visibility, information technology, shared resources and uncertainty/variability (Drupsteen et al., 2016).
The question is what integration barriers arise in a healthcare network setting, because of the involvement of different care providers. Applying a supply chain perspective might help to get insights into the barriers, as Drupsteen et al. (2016) have showed. Continuing the findings of the latter, it is possible that there are additional barriers related to integration in a healthcare network, that barriers of internal integration are not occurring in inter-organizational healthcare integration, or that they might even have a more severe impact on integration. Hence, a supply chain perspective might help to explore the barriers of integration in a healthcare network context.
The research question of this paper therefore is: What barriers hinder integrated care in
healthcare networks, viewed from a supply chain perspective? This study aims to add new knowledge
6 into the barriers of healthcare integration. Since more networks are worldwide being developed to integrate care, this knowledge is of great value to understand how healthcare networks can contribute to the integration of care and what barriers can arise in a network that obstruct integration. Moreover, by understanding the barriers of integration in healthcare networks, managers can use the results of this study in practice to prevent and to reduce the barriers, and to reach a successful implementation of integration.
2. THEORETICAL BACKGROUND
2.1 Healthcare networks
Generally, there are four main stakeholders in healthcare: patients, healthcare providers, healthcare purchasers, and the government (Hardy, Mur-Veemanu, Steenbergen, & Wistow, 1999; Stolper, Boonen, Schut, & Varkevisser, 2019). Care providers comprise different levels, for example primary care, secondary care and tertiary care, and different specialisms, such as mental care and health care (Curry & Ham, 2010). In healthcare networks, three or more different independent healthcare organizations collaborate (Willem & Gemmel, 2013), which in Sweden is known as chains of care: “co-ordinated activities within health care, linked together to achieve a qualitative final result for the patient” (Ahgren, 2003; Curry & Ham, 2010). Healthcare networks are hence a form of inter-organizational collaboration (Auschra, 2018).
There are different characteristics of networks: (1) they have a common goal or purpose, (2) the organizations are independent and autonomous, but are committed to the network, (3) there is exchange (e.g. information exchange) and social interaction, (4) they follow rules, norms and structures of the network, and (5) the participants can be either for-profit, public, or non-profit organizations, and can be competitors (Auschra, 2018). Healthcare networks can have different aims and structures. Firstly, networks can be organized around specific clinical domains as well as complete service domains (Iedema, Verma, Wutzke, Lyons, & McCaughan, 2017). Secondly, different directions can be followed: vertical collaboration along the chain of care, for example comprising primary and secondary care, or horizontal collaboration, for example between primary physicians (Auschra, 2018).
The use of networks can have several benefits. Firstly, because networks provide a structure to work more closely, and allowing continuous working relationships and flow of knowledge about best practices, they can improve the quality of care and access to care for patients (Brown et al., 2016). Furthermore, due to the inter-organizational character of networks, they are viewed as a means with which healthcare systems can counter problems that lie beyond one care provider (Iedema et al., 2017). Also, networks are viewed as a strategy to shift to an integrated care model (Brown et al., 2016) and can reduce fragmentation within healthcare systems (Auschra, 2018). From this point of view, it is not surprising that collaborative networks are being developed in health systems worldwide to integrate their services (Brown et al., 2016).
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2.2 Supply Chain Integration
According to Pagell (2004), a well-managed supply chain is an integrated supply chain, where the highest level of customer value is achieved by letting all value creating processes work together. The goal of an integrated supply chain is to remove all boundaries to ease the flow of material, cash, resources, and information (Lummus, Vokurka, & Krumwiede, 2008). This could also be applied to the healthcare system; there is a flow of patients that go through this system of different, and loosely connected, healthcare providers (Gittell & Weiss, 2004), and with integration the aim is to connect all activities within this flow. Supply chain management literature states that coordination and integration between operational processes might lead to better performance, which could also be applied to the health supply chain (De Vries & Huijsman, 2011).
The meta-analysis of Leuschner et al. (2013) shows that there are multiple definitions of Supply Chain Integration (SCI) and integrated all studies into one definition. Therefore, I follow this definition of SCI, being “the scope and strength of linkages in supply chain processes across firms”. Integration of the supply chain is a key element of a supply chain management strategy, since all the processes ideally need to be designed, managed and coordinated as one unit (Alfalla-Luque, Medina-Lopez, & Kumar Dey, 2013). This strongly relates to healthcare networks that use vertical collaboration, since these are organized around the whole care delivery system and can hence be seen as the supply chain of care.
From a knowledge-based view, the meta-analysis of Leuschner et al. (2013) showed that SCI “can help firms coordinate and deploy knowledge resources by exchanging valuable information across the organizational boundary with key suppliers and customers”. This shows that by integrating inter-organizational aspects, the focal firm itself can benefit. Firms should focus on both the exchange of goods and the exchange of information to achieve SCI, because supply chains mainly have two flows: flow of goods and flow of information (Prajogo & Olhager, 2012). In healthcare, the flow of goods is the flow of patients. Leuschner et al. (2013) identified three SCI dimensions, being: information integration, operational integration, and relational integration.
Information integration
Information integration involves the coordination of information sharing, collaborative communication, and IT that supports the sharing of information between the organizations involved (Leuschner et al., 2013). Clinical information, for example, is highly complex “due to the growth and specialization of clinical knowledge, and due to the multitude of conditions patients may suffer in combination” (Gittell & Weiss, 2004). Therefore, it is important that this information is accurate and appropriate, and organizations must implement a strategy to achieve information integration (Alfalla-Luque et al., 2013). Information integration is mostly facilitated by the use of information technology (IT) (Drupsteen et al., 2016; Prajogo & Olhager, 2012). Moreover, knowledge and skills should be shared to improve performance among supply chain members (Alfalla-Luque et al., 2013). Leuschner et al. (2013) showed that information integration and firm performance are significantly correlated, due to that information sharing enables a more efficient process flow.
Operational integration
8 reduction in costs, lead time and risks, and improvements in customer satisfaction and service levels (Prajogo & Olhager, 2012).
Relational integration
Relational integration encompasses the strategic connection between the organizations involved, which refers to trust, commitment and long-term orientation (Leuschner et al., 2013). This is seen as a prerequisite by Alfalla-Luque et al. (2013) to develop SCI. Only firms with a long-term relationship will be able to reach relational integration, which involves a higher payoff and less risk (Leuschner et al., 2013), and greater commitment and trust (Chen, Paulraj, & Lado, 2004). Additionally, long-term relationships may yield more benefits, including higher probability of firms putting large investments in the relationship, for example for IT (Prajogo & Olhager, 2012). Furthermore, commitment and trust support multiple benefits, such as greater cooperation, reduce functional conflict (Morgan & Hunt, 1994), greater IT customization and strategic information flows (Klein, Rai, & Straub, 2007). Operations literature states that firms usually use formal contracts to align the goals of the organizations (Arshinder & Deshmukh, 2008; Sieke, Seifert, & Thonemann, 2012).
2.3 Integrated care and networks
Integrated care is used as an “umbrella term” because of its broad application (Goddard & Mason, 2017). Kodner & Spreeuwenberg (2002) define the concept as “a coherent set of methods and models on the funding, administrative, organizational, service delivery and clinical levels designed to create connectivity, alignment and collaboration within and between the cure and care sectors”. This definition stresses two important things: the synchronization between the activities of the different organizations, and inter-organizational collaboration. The definition of Hardy et al. (1999) supports this, because it emphasizes the fact that a patient journey mostly encompasses the care delivery of multiple care providers. Hence, inter-organizational collaboration between care providers is crucial for realizing integrated care (Auschra, 2018). Developing a network to integrate care could therefore be an important first step.
Literature has reached consensus about the aim of integrated care, that is to focus on the patient journey, rather than in separate parts based on structures and organizations (Curry & Ham, 2010; Goddard & Mason, 2017). Integrated care is important, because many patients make use of care delivered by multiple, often independent, providers (Auschra, 2018). The benefits of integrated care are versatile, literature mentions improved quality of care, improved quality of life, increased system efficiency, cost reduction, higher client satisfaction, and better access to care (Auschra, 2018; Kodner & Spreeuwenberg, 2002).
Networks with horizontal collaboration integrate care between two or more organizations delivering care at a similar level, for example health and social care (Curry & Ham, 2010; Goddard & Mason, 2017). Healthcare networks that collaborate vertically integrate services between two or more organizations of different care levels, and hence different points in the care pathway, for example secondary and tertiary care (Curry & Ham, 2010; Goddard & Mason, 2017). Furthermore, integration can be real or virtual. Real integration involves mergers, while virtual integration is less strict and can range from “explicit governance arrangements at one extreme to loose alliances or federations at the other”, and is mostly built upon contracts or service agreements (Curry & Ham, 2010). Networks are examples of virtual integration, because these are comprised of multiple independent organizations (Willem & Gemmel, 2013).
2.4 Barriers of integration
9 (Auschra, 2018). Barriers are, hence, not invincible, but can be conquered, and therefore are by some authors seen as the opposite of “facilitators” (Auschra, 2018).
In operations literature, examples of barriers of supply chain integration are lack of consensus on strategy, lack of top management support, lack of communication between managers in different functions, and a mismatch between flow of work and flow of information (Pagell, 2004). From these barriers, lack of consensus was the most important one, because it is considered as a key indicator for integration (Pagell, 2004). Furthermore, Pagell (2004) states that most barriers are inter-related, and that obtaining integration is complex.
A study of Drupsteen et al. (2016) found three barriers to the integrated patient planning in hospitals. First, uncertainty/variability inhibits integration, and mostly this uncertainty/variability is not because of fluctuating patient demand, but because of internal issues. Secondly, they found that shared resources are a major barrier to integration, because of a conflict between the supplier of the resource meeting its performance targets and the user who demands quick access to the resource. The last barrier defined by Drupsteen et al. (2016) is IT, which is more of a facilitating antecedent because integration is not triggered by IT. However, the use of IT does result in better coordination of patient flows. Nevertheless, this study focused on the internal organization rather than on inter-organizational integration, so the question is whether the same barriers arise in a healthcare network setting, and if there are additional barriers that do not exist in the internal hospital. If integration is already hard at the internal hospital level, it is likely to assume that the difficulties between hospitals in a network setting will even multiply.
This was shown by a literature review by Auschra (2018), whi defined twenty barriers divided into six domains. In the highest domain, administrative, four barriers were found, being national borders, regulations, historical developments. In the funding domain, lack of organizational resources and external funding was found to be an inhibiting factor. Five barriers were found in the inter-organizational domain: lack of leadership and coordination, differences regarding collaboration designs and aims, incompatible organizational structures, missing actors, and power imbalances and conflicts. In the organizational domain, cultural distance, former collaboration experience, and organizational versus collective interests were found to be inhibiting integration. In the service delivery domain, six barriers were defined: lack of mutual understanding, lack of trust, lack of technical standards, lack of communication, different professionalization, and resistance to change. In the final domain, clinical, two barriers were found, being lack of information exchange and confidentiality issues.
The question this paper aims to answer is what barriers play a role specifically in a healthcare network setting, viewed from the SCI perspective. Current literature provides little insight into this perspective.
3. RESEARCH DESIGN
3.1 Research setting
In this study, the barriers in healthcare integration are studied from a SCI perspective. There is not much knowledge on this topic, therefore this study is of exploratory nature, and used qualitative research methods. Qualitative research allows to get an in-depth understanding of a real-life phenomenon (Karlsson, 2016, p. 174).
Case study
10 throughout the care pathway and hence with inter-organizational collaboration. Patients that use one of the cardiovascular care pathways see multiple care providers, and therefore seamless connection between the activities of the different providers is crucial, which is done using integration practices. Furthermore, the network aims to solve two issues in the Northern region of The Netherlands: to control the rising costs of cardiovascular care and to improve the regional differing quality of cardiovascular care. Due to these characteristics of the network, this case fits my research well.
HartNet Noord-Nederland both involves vertical integration as well as horizontal integration. It comprises healthcare providers in primary, secondary, and tertiary care, and some of the secondary care providers provide specialized care that not all secondary care providers can do. Furthermore, the integration is virtual, because the organizations are not merged, but are cooperating in a network setting. HartNet Noord-Nederland developed multiple care pathways to re-organize healthcare among the different providers in the network, and to synchronize the activities of the different care providers. Because of the inter-organizational integration of activities, this case fits the research question.
Unit of analysis
The unit of analysis is the patient journey of patients in a regional care pathway of cardiovascular care. Two care pathways are chosen, in accordance with the initiator of the network; ablation and TAVI. Both care pathways used in this study are in operation since April 2019, and therefore are the longest existing care pathways of the network. Hence, they can provide the most valuable knowledge on the barriers of healthcare integration. The care pathways are current cases, and since the development of the network and the care pathways is rather recent, this study enables to capture the barriers and possible future barriers that are due to the changes in the healthcare system.
Ablation is a treatment for patients with arrythmia. An arrythmia affects the heart rate of a patient, and the heart rhythm is either too fast, too slow or irregular. Not all patients who have arrhythmia need ablation; it is also possible to be treated with medicines, a pacemaker, an ICD or cardioversion. With ablation, the electrical stimuli that determine the rhythm are being blocked. This is done by damaging the heart tissue, and the scars that will appear will block the wrong electrical stimuli. There are different types of ablation, depending on the complexity of the arrhythmia. Risk factors of arrhythmia increase with age, which causes the patients in the ablation care pathway to be mostly elderly (the average age is approximately 65 years).
TAVI is the treatment of a disability of the aortic valve, also known as aortic valve stenosis. When a patient has aortic valve stenosis, the heart valve will not open fully, which makes the blood flow less easily from the left ventricle to the aorta. The heart’s pumping power declines, which can lead to heart failure and arrhythmia. With TAVI, the aortic valve is being replaced using a catheter or is repaired. An aortic valve stenosis is mostly congenital or occurs in old age. The average age of a TAVI patient is about 80 years.
Hence, two cases are studied. However, because the results did not differ specifically between the different care pathways, I chose to analyze the cases as a single case. By using a single case, an in-depth case study was conducted. This suits the research question of this study, because it contributes in finding explanations in order to enrich theory on the barriers in healthcare integration (Karlsson, 2016, p. 166). Moreover, because healthcare is a complex context, a case study can help to get a full understanding of this complexity (Karlsson, 2016, p. 167).
Nature of the research
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3.2 Data collection
The primary data this study uses are exploratory conversations with the project leader and initiator of HartNet Noord-Nederland, interviews with healthcare professionals involved in the chosen care pathways, documents about the network structure and about the care pathways, and observations. The exploratory conversations and the documents about the network structure are used to get an overview of the research context and the case setting. The other data sources are used for the analysis.
Interview protocol
THE INTERVIEWS ARE SEMI-STRUCTURED, BECAUSE THE PURPOSE OF THIS RESEARCH IS TO GET AN IN-DEPTH
UNDERSTANDING OF THE TOPIC. THIS ALLOWS TO ASK MORE QUESTIONS IF NEEDED, AND TO DEVIATE A LITTLE BIT FROM
THE INTERVIEW PROTOCOL WHERE APPROPRIATE. THE INTERVIEWS CONTAIN MOSTLY OPEN QUESTIONS, BECAUSE OF THE
THEORY BUILDING NATURE OF THIS RESEARCH, AND ARE HELD IN DUTCH. THE INTERVIEW PROTOCOL IS AIMED AT
MAPPING THE CURRENT WORKFLOW OF BOTH CARE PATHWAYS, AND TO UNDERSTAND THE ACTIVITIES, COLLABORATION,
AND WAY OF WORKING, IN ORDER TO DISCOVER THE BARRIERS IN THE NETWORK. THE INTERVIEW QUESTIONS ARE BASED
UPON THE THREE SCI DIMENSIONS AND THE CHARACTERISTICS AND PROCESS STEPS OF THE CARE PATHWAYS TAVI AND
ABLATION. THE INTERVIEW PROTOCOL, BOTH IN ENGLISH AND
DUTCH, CAN BE FOUND IN REFERENCES
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14 Appendix A: Interview protocol. The protocol is the same for all interviews, except for one topic: strategy and alignment of goals. This topic is only discussed with the managers, because they are involved in the strategy of the individual organizations and of the network.
During the interview phase, the interview protocol was updated and improved after each interview, when necessary. For example, during the second interview I noticed that a question about information sharing with patients was missing, so I added this to the protocol afterwards. And in order to prevent the interviewees from giving socially acceptable answers, after the second interview I added a note about this to the introduction of the interview. This iterative process suits theory development (Glaser & Strauss, 1977).
Interviewees
The interviewees are contacted in consultation with the initiator of HartNet Noord-Nederland. The selection criteria for selecting the interviewees can be found in Table 3.1. By using multiple interviewees, the construct validity can be tested (Karlsson, 2016, p. 184). Moreover, because people with different positions and of different organizations in the network were interviewed, triangulation is ensured. The aim was to interview at least one healthcare professional and management professional per hospital organization and two GPs who are involved in HartNet Noord-Nederland, to give a good overview of the different perspectives of the people and organizations involved in the network. Table 3.1: Selection criteria interviewees
Selection criteria
The interviewee is an employee of one of the hospitals of HartNet, or is a GP that is located in Groningen or Drenthe.
The interviewee is working for this employer at the time of conducting the research.
The interviewee was also working at the same organization before the development of the care pathways.
The interviewee is involved in cardiovascular healthcare, and specifically involved in the care pathways TAVI and/or ablation.
However, due to fully booked schedules and the proposed time frame for conducting the interviews, it was not possible to interview all intended interviewees. Furthermore, based on the analysis of the interviews, an additional interview with a cardiologist was conducted to add more input on some topics, and one of the manager interviewees was e-mailed afterwards to clarify something about one of the topics. Hence, the total number of interviewees ends up being 13 (see Table 3.2), divided over 12 interviews.
Table 3.2: Number and type of interviewees Type of
interviewee
Number of interviewees
Knowledge about the care pathway
15
3.3 Data analysis
After conducting the interviews, they were transcribed within five days. The interview recordings were stored on a secured laptop that is owned by the researcher, and were only used for research purposes by the researchers involved in this study. The recordings, nor the transcripts, were not shared with others than the researchers. Before the coding phase, the transcripts were anonymized in order to guarantee the anonymity of the interviewees.
For the codification of the transcripts, Atlas.ti was used, and the coding scheme of Strauss and Corbin was adopted (Karlsson, 2016, p. 186). Because of the broad nature of the interview protocol, most parts of the transcripts were not usable and therefore not coded, and only the parts related to barriers were coded. During the coding process, the sections of the individual interviews were examined thoroughly, in order to unravel the core concepts of the sections and to define the right code for each section. By using the list coding function in Atlas.ti, it was possible to use the same codes for similar sections, and it was not necessary to delete a lot of synonyms afterwards. However, some codes were merged afterwards, where applicable, in order to clean the amount of codes. For example, “transferring of care” and “transferring of tasks” were merged into “transferring of care”. Another example is the merge of “knowledge level GPs” and “knowledge level cardiologists”, because there were just a few quotes of both. This iterative process is characteristic for qualitative theory building research (Pagell, 2004). After the coding was done for all individual interviews, four core coding categories were used in order to structure the concepts: informational barriers, operational barriers, relational barriers, and other barriers, of which the first three categories are in line with the theoretical framework about SCI. The last category was added because the three others did not cover all codes, and later on was labeled as “financial barriers” or “organizational barriers”, according to the specific quote and code. After this, the core categories were analyzed one by one. During this process, the coding was strengthened again, making improvements in terms of consistency and structure, to come up with the final coding tree.
4. RESEARCH CONTEXT
In order to understand the results of the case study, the research context will be outlined first by describing the two care pathways and the changes in these pathways.
4.1 Care pathways
HartNet Noord-Nederland developed multiple care pathways in order to standardize the processes. In this paper, the care pathways TAVI and ablation are studied, and the flow charts are displayed in the figures below (see Figure 4.1 until Figure 4.6). Usually, for a patient, the flow starts at the GP, but since the diagnosis is not known at this point the flow chart starts when a cardiologist makes the decision to start one of the two care pathways.
TAVI
A patient will enter the TAVI care pathway when a disability of the aortic valve has been determined. In Figure 4.1 and Figure 4.2Figure , the old and new flow charts of this process are visualized. To both situations applies that the patient will go to the university medical center for the treatment, because this is the only hospital in the network that is capable of executing this treatment.
16 appointment to discuss the treatment and to get the last needed information for the TAVI treatment, and after the treatment there is a post treatment outpatient clinic appointment to measure the results of the treatment. The final follow-up was also done by the academic hospital.
Currently (Figure 4.2), once a presumption of the disability is made by a cardiologist in a general hospital during an outpatient clinic appointment, and the diagnostics to determine the disability are done, the diagnostics are sent to the academic hospital. With this information, the patient will be discussed during a multidisciplinary meeting hosted by the academic hospital. In the new situation, the final follow-up is done in the general hospital.
Figure 4.1: Flow chart TAVI (old)
Figure 4.2: Flow chart TAVI (new)
Ablation
Patients who have a heart rhythm disorder can get an ablation to treat this disorder. There is a distinction between low complex patients (Figure 4.3 and Figure 4.4) and high complex patients (Figure 4.5 and Figure 4.6). For both kinds of complexity, the academic hospital is the only hospital in the network that can do the treatment, so the patient will always visit the academic hospital.
17 that the outpatient clinic and diagnostics were re-done when the patient was being referred from a general hospital to the academic hospital. From the moment that a patient was being referred to the academic hospital, the whole care pathway would be executed here.
After the development of the care pathways, the low complex patients will go to the general hospital for both the pretreatment outpatient clinic and post treatment outpatient clinic (see Figure 4.4), but for high complex patients these appointments remained in the academic hospital (see Figure 4.6). The final up is transferred to the general hospital for both pathways. The timing of this follow-up is also determined according to the complexity of the disorder, it can be 3, 6 or 12 months after the treatment.
18 Figure 4.4: Flow chart ablation low complex (new)
19 Figure 4.6: Flow chart ablation high complex (new)
5. RESULTS
A total number of 10 barriers were found, divided over five categories: operational barriers, informational barriers, relational barriers, financial barriers, and organizational barriers. Hence, I follow the three integration dimensions of Leuschner et al. (2013), and added two other dimensions where these three did not suffice. Additional interview quotes can be found in Appendix B.
5.1 Case analysis
An overview of the 10 barriers that were found is shown in Table 3. The first financial barrier was mentioned by the majority of the interviewees, the other barriers were mentioned by a fewer number of interviewees. Each barrier will be discussed in the next sections.
Table 5.1: Number of interviewees that mentioned the specific barriers Type of integration barrier Specific barrier # of doctors # of managers # of GPs # total
Operational Misalignment of schedules 1 0 0 1
Operational Insufficient medical knowledge GPs 1 1 1 3
Informational Lack of post treatment feedback 1 0 0 1
Informational Lack of information sharing 3 1 0 4
Informational Lack of connection between IT systems
3 0 0 3
Relational Lack of alignment between
individual organizations’ goals and network goals
1 1 0 2
Relational Lack of employee involvement 1 1 1 3
20
Financial Non-declining costs 1 0 0 1
Organizational Non-facilitating type of legal entity 1 1 0 2
5.1.1 Operational barriers
Misalignment of schedules
If a patient is referred from the general hospital to the academic hospital, there is a multidisciplinary meeting at the academic hospital where the patient will be discussed. In this meeting, the diagnostics are used to come to a proposed treatment. In order to get joint decision making, it is possible for the cardiologists of the general hospitals to attend the multidisciplinary meeting via videoconferencing. However, this is not always possible to attend for everyone, because the different schedules are not integrated. This causes less involvement in the decision making process and might affect the outcomes:
Cardiologist (CAR004): “I think it’s good that we have the possibility for video
conferencing, but it’s not practical to work with, because we can’t block a certain timeslot during our outpatient clinics to attend the video conference. (…) But for a lot of patients it’s no problem that we don’t have the video conference, because it’s clear cut and not complex. However, for complex patients it would add value, but then it’s important to plan the meeting at a realizable time, because we can’t plan our outpatient clinics around a possible video conference which may even be cancelled.”
This cardiologist (n=1) explains that the lack of involvement in the decision-making process is not always a problem, because there is a difference in the complexity of patients. For non-complex patients, the lack of joint-decision making is no problem, but for complex patients, the cardiologist does think it would affect the outcomes of the decision if the general hospital is involved in the decision-making process. The misalignment of schedules stems from the inter-organizational collaboration in the network where individual organizations plan meetings according to their own schedule, without taking other organizations’ schedules into account. Hence, there is no integrative planning in order to facilitate shared decision-making.
Insufficient medical knowledge GPs
The GP questions the knowledge level of primary physicians. GPs can attend refresher courses to update their knowledge on specific topics. However, these courses are voluntarily, so it is not certain that all doctors have the right knowledge to take care of their patients.
General practitioner (HUI001): “We did a refresher course about TAVIs, so doctors who
were there know what an umbrella is. But I do wonder whether the rest of the doctors know. They will get a letter from the cardiologist that the patient needs an umbrella, and they think: ‘sure’. But then the patient needs to be de-clotted, and that’s dangerous. Because, are we doing it the right way? So the knowledge level of the doctors is a challenge.”
Therefore, if HartNet wants to transfer tasks from secondary care to primary care in the future, it is really important that the GPs have the right knowledge to do this. Without the required knowledge, it is not possible for the GPs to perform certain tasks. Therefore the connectivity between the care pathway processes is lost, because the tasks that the GPs are intended to perform cannot be executed or are executed in the wrong way.
5.1.2 Informational barriers
Lack of post treatment feedback
21 established a feedback cycle yet with which the cardiologists of the academic hospital get feedback, and hence this feedback is lacking:
Cardiologist (CAR003): “I’m not informed about the post-ablation care. We used to see
all patients after the treatment, and we would know exactly about every patient’s condition, but now we don’t. (…) We should really think about how we implement getting feedback about the outcomes of the treatment.”
This lack of feedback could become a barrier for the quality of care, because the cardiologists cannot adjust their working method accordingly to the feedback. This threatens integration, because there is no connection between the follow-up with the patient at the general hospital and the following feedback towards the surgeon of the academic hospital. This issue was mentioned by only one doctor (n=1), but since this was the only academic cardiologist that was interviewed, and they execute the treatment, this explains why this is not mentioned by the other cardiologists.
Lack of information sharing
This topic is the second most mentioned topic by the interviewees (n=4). Within HartNet, a lot of information is shared between the hospitals in order to provide the best care for the patient. In the new process flows, it is even more important to share the correct information, because the diagnostics are done in the general hospital, and the academic hospital uses these to make the right decisions about the treatment. However, the shared information is not always complete, according to some interviewees. Firstly, the referral information is incomplete:
Cardiologist (CAR003): “I think that the referrals could be more complete. There are still
some colleagues that send in incomplete referrals. Then we have to judge a situation based on incomplete information, which makes that we are spending a lot of time on completing the letter or calling a patient.”
Secondly, incomplete information occurs with sharing the outcomes of the disciplinary meeting about the treatment decision:
Cardiologist (CAR001): “I think that the result of the meeting often is too short. Then I
don’t get, one time the result said ‘we agree with the procedure’. But it was a patient from [hospital], I didn’t have a letter from the [hospital], so I thought ‘what kind of procedure?’ (…) Then what? A pacemaker? An ICD? It shall be an ICD, but 1, 2 or 3 dreads? I don’t know.”
Thirdly, information is missing about the planning of the process steps of a patient journey: Manager (MAN003): “Sometimes we don’t know if a CT scan is planned, when it’s
planned, and when the results are ready. Then we’re waiting for the results of the CT scan to continue the process. (…) This happens sometimes currently, it’s not fully synchronized yet. That should be better, we’re working on that.”
Hence, not all information that is needed is shared between the hospitals, which makes it more difficult to make decisions about the patient’s treatment or to continue the process in the right way. Without complete information, it is not possible to continue the care pathway according to the developed processes, because doctors need to gather more information before they can perform their activities. This hinders integration, because there is no alignment between the different process steps.
Lack of connection between IT systems
22 Cardiologist (CAR004): “The IT connection between the hospital systems is really bad.
(…) we can send videos, but only if there’s no interruption. (…) It is really annoying that if [academic hospital] sends something to our hospital secretary via e-mail, they need to print it, need to put a sticker of the patient on it, need to scan it into the system, and couple it to the right patient. That is undesirable, there should be just one button to do all that.”
Cardiologist (CAR001): “Sometimes, when a patient went to the [academic hospital] he
has undergone lab research, we can’t see that, because the lab of [academic hospital] is their own system, it’s information of what they’ve done and we can’t see anything. Only the outcomes of the research, or if there’s a letter we can see what’s written in the letter. (…) And the feedback, that’s a pity, if we get the information, sometimes we get a whole pack of paper, and that’s not useful because we have to scan everything into our system. (…) We get 20 pages, and we have to click through them. (…) It would be an improvement if we can look into each other’s systems.”
These cardiologists explain that the IT connection between the different IT systems of the hospitals is not efficient. If they exchange information about a patient, they cannot automatically add the files and other information into their systems, but they need to manually add it instead. Due to this way of working, there is a high risk of wrong or missing information. Furthermore, sometimes the information is not even possible to see, because not all systems are able to exchange information. This creates a lack of information or a lack of complete information, and hence the connectivity between the different process steps is disturbed.
5.1.3 Relational barriers
Lack of alignment between individual organizations’ goals and network goals
HartNet Noord-Nederland consists of five hospital organizations, who all have their own organizational goals. Currently, all hospitals are working conform the goals of the network, but in the future the individual goals of the different hospitals might not overlap with the goals of the network. Examples mentioned by the interviewees are the connection between IT systems, financial interests, transfer of care, and education and research as main goals of the academic hospital:
Manager (MAN001): “As long as HartNet fits the organizational goals the HartNet goals
will be accomplished, but when it doesn’t fit anymore HartNet will most likely lose it. And we haven’t been in situations where that has happened yet, but I know something of which I think it will happen. Because we think that, for HartNet to perform optimally, you want to exchange information structurally, such as healthcare data that you need in the consulting room, but also quality data to assess whether we’re conforming to what we’ve agreed upon, throughput times, that kind of stuff, and to exchange this information structurally with each other we want to connect our EPDs [digital patient files], but all the individual IT departments have their own hospital-wide priority list, and HartNet is just one of the 16 things on that list.”
Manager (MAN003): “The second goal of our hospital is education and I think that’s
something, research, where we’re still searching how we can still satisfy that goal while our patients are transferred to the peripheral hospitals. So we’re making agreements about how to deal with academic research, when patients are not visible during the follow up care.”
23
Lack of employee involvement
There is a perceived lack of involvements of doctors and GPs (n=3), which makes that agreements are not complied with:
Manager (MAN003): “The relationships between the managers are good, but there are
also other cardiologists. Furthermore, at [hospital] there’s three different locations, so our relationships can be good, but that doesn’t necessarily mean that the doctors are working according to what we agree upon. So there are some challenges there.”
The medical managers and business managers involved in HartNet all know about the agreements made in the network, but the perception is that this is not always communicated well enough throughout the organization. This is also supported by an observation of a secretary who did not know about the HartNet protocol.
Observation (OBS001): A doctor corrects a secretary by returning the referral form and
telling her that she needs to refer the patient according to the HartNet protocol, and not according to the ‘regular’ protocol. The secretary doesn’t know about this protocol, and later on asks another secretary how to do this. The other secretary explains that there is a HartNet e-mail address, and that she will look it up later on.
Hereby, people are not working according to the agreements and processes, which hinders the connectivity between the different process steps of the care pathways. This may be explained by the multiple positions that a hospital manager holds which makes communicating the HartNet agreements not always the manager’s first priority. Hereby, employees are less involved:
Manager (MAN003): “Sometimes I notice that we’ve made agreements with managers or
medical managers, and if you look a bit further into the organization, not every secretary knows what to do, or every nurse knows what HartNet is. Some managers are not only managing the cardiology department, but are for example also the managers of the lung department, internal medicine, so they’re working with different organizational structures.”
Due to multiple positions, the network agreements may not be the highest priority of these managers. Furthermore, the perception of the GP is that primary physicians do not know about HartNet and the expected plans yet, which may hinder the willingness to cooperate in the future:
General practitioner (HUI001): “But the problem is that, as a GP, I don’t know about
HartNet yet. (…) Today, there is just a little known about the effects of HartNet on our work. (…) I think it’s time to involve the GPs into the thoughts of HartNet, even if you don’t know what will happen yet. Because if there’s something figured out later on and we think: ‘it’s decided for us, but not with us’ (…) I do worry about that.”
Because of the inter-organizational nature of healthcare networks, there are multiple organizations and hence there is a multitude of people to involve into agreements. This makes integration of agreements important, but the above shows that is also difficult. If the people that are involved in the care pathways are not involved in the process changes and agreements, the care pathway processes might not be executed according to the agreements. Furthermore, the lack of GP involvement might cause distrust. 5.1.4 Financial barriers
Perceived non-adjusted payments
24 Cardiologist (CAR002): “For example, we [general hospital] need to make CT scans of
the long veins, and they want us to do that because the patients can get an appointment quicker, and we can do that, but we don’t get money to do it, for this CT scan. And of course, they [the academic hospital] do get money for it. (…) Look, we’re not an hospital with huge financial buffers, like you’ve read in the newspaper, so if we will get paid for this scan then of course, we dan co it.”
The sentiment prevails that the process has changed, but the payment of the purchaser has not changed. Especially for a general hospital, also known as a peripheral hospital, finances are extremely important, another cardiologist explains:
Cardiologist (CAR005): “(…) when you’re working in the periphery everything is about
the money.”
Another cardiologist is critical about the sentiment that the academic hospital is still getting money for the deleted CT scan, and explains that the diagnosis treatment combination (DOT) payment will be adjusted afterwards, so it will eventually work itself out:
Cardiologist (AANV001): “The DOT price is determined afterwards, and hence will
change. So if I’m currently getting 100 euros for a DOT and I stop doing bicycle tests, next year my DOT will become cheaper, because I deleted the bicycle tests. And the purchaser knows, so the DOT price will be adjusted accordingly. This also happens with the CT scan that is currently included in our DOT price. We have a higher DOT price because of this CT scan, but the CT scan will be transferred to the general hospitals, which means that my DOT price will change and we will get less money. It will solve itself. But I don’t know if the peripheral hospitals use this system too, or if they have a different deal with the purchaser. If they have the same system it would mean that they are doing more, so their DOT price will rise, and they will get more money.”
This cardiologist also explains that this is such an important issue for the cardiologists in the peripheral hospitals because this is connected to the cardiologists’ salaries:
Cardiologist (AANV001): “I’m getting a monthly salary, and of course I’m judged based
on my production. If I’m doing too little I have to give up formation, but my salary will never change. (…) For them [cardiologists in a peripheral hospital], their salary will change if they do not meet their prospected production, because both of them are connected. They have a payment deal with the hospital, they are independent (…) and these deals are based on production. For them the production is really important, because it’s their salary. If they are doing a lot of care, see a lot more patients, their production will rise and they will get more money.”
One of the managers explains that the finances could become a breaking point in the future, because of the same reasons mentioned by the cardiologist above. This manager adds that currently the volume of patients is still growing, which makes the finances less of an issue. However, in the future, if the volumes increase, it might become more of an issue:
Manager (MAN002): “Because, when you’re going to talk about finances, it won’t work.
25 Hence, there is a difference in perception of financial importance between the managers and the cardiologists. The managers agreed that the outcomes and quality of the network are currently more important than the financial consequences, and that the payments will eventually follow. This difference in perspective might cause friction and distrust in the future.
The same issue will probably arise when tasks of the general hospitals will be transferred to the GPs, in the future:
General practitioner (HUI001): “We’re getting money for the atrial fibrillation chain of
care,. If doctors are getting money for their tasks, we will complain less compared to if we’re not getting any money.”
If financial issues like these are not solved, this might hinder integration in the long-term, because care providers might refuse to perform specific tasks. Furthermore, the different opinions about the finances might cause friction which could eventually end up in distrust between parties. This barrier relates to the different goals of the hospitals, because the financial goals of the hospitals are organized differently.
Non-declining costs
Financial issues might have far-reaching consequences. One of the reasons HartNet exists, a cardiologist explains, is because the Dutch ministry wants to reduce the healthcare costs, which is done by transferring care from secondary care to primary care. This might not have the intended result, because the costs of general practices will also rise due to this shift. The cardiologist explains that this might threaten the motivation to pursue the network’s goals in the future:
Cardiologist (AANV001): “They [general practices] are becoming small hospitals. They
have four or five GPs, four or five nurses, a physiotherapist, he bought the rhythm monitoring from a commercial party, he buys lab from a commercial party. It’s becoming a small hospital, and in the end the costs of all these small hospitals will rise. Because we’re transferring more and more patients to primary care, they have to do more and more tasks, so the costs will definitely rise. In the end it will come closer to each other: GPs will become more expensive, peripheral hospitals will become more expensive, and university medical centers will become less expensive. That’s how it goes. And a GP will never become as expensive as an university medical center, but we will come closer to each other. I’m convinced of that. So eventually, over the years the financial benefits will decline and therefore the motivation to pursue this, too.”
The perception is that due to transferred care, the future expectation of care provided by GPs is increasing, which also drives up the costs. Since one of the reasons of existence of the network is to control the costs, this might hinder the network’s future. The consequences therefore can be far-stretching. Since the network is the facilitator of integration, this obstructs the overall integration between the care providers.
5.1.5 Organizational barriers
Non-facilitating type of legal entity
Currently, the organizational structure of HartNet is a foundation, but this does not enable the network to steer on certain goals and it can threaten the success of the network’s goals. This might lead to problems in the future, when the network will come across topics that are fundamental for the continuation of the network, such as financial responsibility and IT connection. Two of the interviewees describe their doubts about the type of legal entity clearly:
Manager (MAN001): “Because we’re not a legal entity and we didn’t statutory define
26 Cardiologist (AANV001): “It’s always about the money, it has a lot of influence. We can
do what we want now, but that’s the reason I want to shift to another legal entity, because we notice that it is getting harder. Everyone has to perform tasks and has to provide data, and there’s a continuous discussion about who is going to pay for it, because providers are doing more than before. And I’m like, who will pay for it? You want the patients back sooner, so deal with it yourself. That’s what a lot of discussions are about.”
When the achievement of goals is obstructed because of the type of legal entity, this can hinder integration because agreements, for example about the care pathway processes, might not be complied with. This creates a disconnectedness between the activities of the different care providers. This barrier relates to the alignment between individual organizations’ goals and network goals; in order to reach the network’s goals, the network needs more power, which the current legal entity type does not provide. 5.1.6 Inter-relation between barriers
Some of the barriers are inter-related and can be used to explain other barriers (see Figure 5.1). Firstly, the lack of post-treatment feedback and the lack of information sharing can be partly explained by the lack of connection between IT systems, since a connection would facilitate the feedback and information sharing more easily. The IT system does not allow doctors to share feedback automatically or in an easy, manual way. Furthermore, because post-treatment feedback is a kind of information sharing, this also relates to the lack of information sharing.
Secondly, the lack of connection between IT systems can be explained by the lack of alignment between goals, because the managers involved in the network do want a connection between the different IT systems, but the individual organizations’ goals and priority lists do not facilitate this on a short term. Thirdly, lack of goal alignment and type of legal entity are related, because different legal entities influence the power of the network and therefore the possibility to align the different goals. Lastly, the perceived non-adjusted payments are related to the lack of goal alignment, because the network goals focus on quality first, but cardiologists in some hospitals do want to adjust the payments right away, because it affects their salaries.
Figure 5.1: Inter-relation of barriers
6. DISCUSSION
27
6.1 Operational barriers
Two operational barriers were found in the case study: misalignment of schedules and insufficient medical knowledge GPs. Firstly, shared decision-making with network partners is one of the integration tools (Alfalla-Luque et al., 2013), and misalignment of schedules obstructs this decision making with multiple care providers. Therefore, this study points out that integrative planning might not only be important for controlling waiting times for patients (Drupsteen et al., 2016), but may also be of interest to collaborating professionals in an inter-organizational healthcare network setting. For managers, this shows that when inter-organizational decisions need to be made, integrative inter-organizational workforce planning should be taken into account. The insufficient medical knowledge GPs stems from expected future process changes, and was not identified as a barrier in literature before. This might relate to the specific characteristic of this network to transfer care between care providers, which is not occurring in all healthcare networks or inter-organizational collaborations, and is mainly a once only event. For healthcare managers, it is important to analyze the consequences of process changes before these are realized, to be able to prevent their negative impacts. In this case, GPs could be trained or supportive tools could be designed in order to overcome insufficient knowledge.
6.2 Informational barriers
The informational barriers that were found are obstructing the connectivity of the process steps of different care providers. The different information technology systems of the different hospitals are the main cause for the lack of information exchange, which is a known barrier in inter-organizational collaboration, as well as the lack of information exchange itself (Auschra, 2018). Therefore, this paper supports both barriers. The IT barrier is the only barrier that is in line with the barriers found by Drupsteen et al. (2016), but in contrast to their findings, IT might not be a facilitator but a real barrier due to the fact that some information cannot be shared at all with non-connected IT systems. Therefore, the impact of this barrier depends on the context of integration (internal or external). Furthermore, because IT is expected to solve the other two informational barriers, this paper encourages managers to take IT into account before even starting the development of a healthcare network. By developing a connection between the IT systems, or even building a network IT system, managers can prevent these informational barriers and their effects.
The lack of post treatment feedback was not identified as a barrier before. This might be due to the fact that it is an outcome of the process changes in the care pathways, which is a specific characteristic of the healthcare network that was studied. For managers it is therefore important to analyze the consequences of process changes before these are actually realized, to be able to prevent their negative impacts.
6.3 Relational barriers
Two relational barriers were found. Misalignment between goals has been defined as a barrier to inter-organizational collaboration (Auschra, 2018). This study therefore supports that misalignment of individual organizations’ goals and network goals is a barrier to integration. The lack of goal alignment was part of the interview questions about strategy, which was only asked to the managers. Hence, it makes sense that this is not mentioned by cardiologists, even though one cardiologist indirectly suggested this. The implication for practice is that network managers should determine if there is a possibility of goal conflicts and what effects this may have on the realization of network goals.
