INTERPRETING INTEGRATION IN ACUTE
CARE, RESEARCH ON BARRIERS TO
INTEGRATION
Master thesis, MSc SCM,
University of Groningen, Faculty of Economics and Business
October 10, 2017
JURRIËN MOERMAN
Studentnumber: 2171635
e-mail: j.moerman.3@student.rug.nl
First supervisor/ university
R.E. Gifford, University of Groningen
Second-assessor, first examiner/ university
prof. dr. J.T. van der Vaart, University of Groningen
Second examiner/ university
1
ABSTRACT
This research investigates the barriers towards internal integration from a relational view in the uncertain context of acute care. We add to the healthcare literature, where research on integration is scarce and answer the call from crowding literature to investigate integration in acute care. In literature, three barriers were found that possibly influence internal integration in acute care: financial incentive, lack of commitment and lack of trust. The study is based on a single exploratory case study. The findings stem from 7 in-depth interviews with ED
3
INTRODUCTION
Preventable life-threatening events and even death are still significant problems facing contemporary healthcare (Harrison et al., 2015). In the Netherlands, adverse event rates increased 4.1% from 2004 to 2008 (Baines et al., 2013). Thus, patient safety and improving the quality of care is still a critical issue. In the influential work “Crossing the quality chasm” it is highlighted that to improve the quality of care, the integration of care across patient conditions, services and departments needs to be improved (Glover, Li, Naveh, & Gross, 2017; Institute of Medicine (US) Committee on Quality of Health Care in America, 2001). Overall, in supply chain, and operations management there is empirical evidence that there is a relationship between integration and performance in firms (van der Vaart & van Donk, 2008). Furthermore, multiple case studies researching the relationship between integration and performance found a positive relationship (van der Vaart & van Donk, 2008). Moreover, in healthcare literature, where research on integration is scarce (Drupsteen, van der Vaart, & Pieter van Donk, 2013), positive relations between integration in healthcare and performance have been found (Bechtel & Ness, 2010; Gittell, Seidner, & Wimbush, 2010; Glover et al., 2017).
In acute care, where there is a high rate of patient turnover and shorter length of stay, the management of patients requires complex analysis where multiple medical specialists are involved (Sutcliffe, Lewton, & Rosenthal, 2004). Thus, because of the multiple specialists involved, critical information needs to be communicated efficiently (Sutcliffe et al., 2004). In order to communicate efficiently, the specialists need to share information, collaborate and work together, which is the essence of internal integration (Zhao et al., 2010a).
On the emergency department, where acute care takes place, different specialties have to work together when patients need to be admitted to the hospital or in case of very acute and complex patients where multiple specialists are directly involved in treating the patient. To improve patient safety and health quality, it is widely considered that the use of integrated health systems provides superior performance through effective communication and
4 Furthermore, it has been shown that crowding on the emergency department increases
mortality, length of stay and costs (Sun et al., 2012). Integration can be the solution to better acute care, and there also has been a call from crowding literature to investigate integration in acute care (Hoot & Aronsky, MD, 2008).
While integration can improve the overall performance of healthcare and this can be achieved by better communication and collaboration between departments in the hospital, it is
interesting to investigate what the barriers to integration are in the emergency department. Therefore, the research question is:
What are the barriers to internal integration between the emergency department and different specialties inside the hospital?
This thesis will contribute and expand the research on facilitators and inhibitors of
5
THEORETICAL BACKGROUND
The emergency department
The emergency department (ED) can be described as a hospital department that provides care for patients with acute diseases or injuries (Nawar, Niska, & Xu, 2005). The US was one of the early adopters of the ED where they have had ED’s for over 50 years (Suter, 2012). In the Netherlands, before the actual profession of emergency physicians, medical specialists had the job of providing emergency care. The profession of emergency physician is relatively new in the Netherlands while it became a specialty in 2007.
From a supply chain perspective, the emergency department is different from other departments in the hospital because the patient flow in the emergency department is very unpredictable (Reddy & Jansen, 2008). The unpredictable flow and the variety of illnesses and injuries make for a complex environment. In general, the ED is staffed by ED physicians and residents from different specialties. A patient who comes into the ED is either sent home after treatment or gets admitted to the hospital. In both instances, the staff of the ED nearly always has to work together and collaborate with different departments of the hospital. In this process integration is important (Suter et al., 2009). Moreover, when looking at the hospital from a departmental point of view, the specialists that often have to work together with the ED physicians thus do not only work for their own department, but also for the ED, making them a shared resource. Shared resources are often mentioned as a facilitator for integration, but this is dependent on the situation.
Shared resources and uncertainty
6 radiology department but also works in the emergency department. This increases the
complexity of the supply chain and is also an example of shared resources (Aronsson, Abrahamsson, & Spens, 2011). Although every doctors’ goal is to provide quality care for patients and they are willing to work together, the fact that most doctors are a shared resource, of the emergency department and their own department, is a barrier towards integration while they are often too busy working on their own department.
It can be said that the ED is part of a complex supply chain while it has to work together with all the other departments. This is because patients that come to the ED, most of the time, need to receive care from a specific specialty. Also, what is making it even more complex is that no arrival is planned because it can never be known when someone will be acutely ill. Having established that the ED is a complex and uncertain environment, shared resources can,
according to literature (Van Donk & Van Der Vaart, 2005), form a barrier towards
integration. In this research, however, shared resources will be considered as a factor that is inherent to the ED because of the unpredictable nature of demand and variety of patients on the ED.
Integration
Although there has been much research on integration (Power, 2005), little research has been conducted on integration in the healthcare context (Drupsteen et al., 2013), let alone in acute care. Hence, it is necessary to draw from different fields of research, to gain more insight into integration. Integration can be divided in internal integration, integration within the company, and external integration, integration between companies (Zhao et al., 2010), this is also called the scope of integration (Leuschner, Rogers, & Charvet, 2013)
In this research, we will look at integration within the company, which is, in this case, the hospital. Internal integration can be used to improve communication between departments. Internal integration can be summarized as information sharing between internal functions, strategic cross-functional cooperation and working together (Zhao et al., 2010a).
7 (Barratt, 2004; Kahn & Mentzer, 1996). These organizations are not able to achieve full internal integration because they are missing joint goals, shared resources and a common vision, in other words, a collaborative approach (Barratt, 2004).
In supply chain management literature, every different function in a firm that is internally integrated does not act as a functional silo but instead is part of an integrated process (Zhao et al., 2010). In the acute care setting these functional silos can be seen as the emergency
department and the different specialists' wards and the intensive care unit (Van Galen, n.d.). It is of utmost importance that information can be shared easily between these different departments and that they work together effectively and in a timely fashion. This is especially true in the emergency department where there are high error rates, which could have serious consequences (Cheung et al., 2010).
While information sharing, cooperation and working together all summarize internal
integration, researchers have studied the inhibitors of internal collaborative behavior to find a way to improve internal integration (Ellinger, Keller, & Hansen, 2006). Five themes were found that inhibit internal collaborative behavior: insufficient knowledge of other functions, lack of communication, poor working relationship, conflicting goals and lack of direction from senior management (Ellinger et al., 2006). In addition, to achieve internal integration, it is important to have integrated data and information systems (Zhao et al., 2010a). While there is empirical evidence that integration is linked to performance in firms (van der Vaart & van Donk, 2008), and also in healthcare (Bechtel & Ness, 2010; Gittell et al., 2010; Glover et al., 2017), it is important to find out what inhibits this relationship in acute care.
Barriers to integration
In healthcare, only general behavioral and organizational factors have been identified as barriers towards integration (Drupsteen et al., 2016). Therefore, Drupsteen et al. (2016) have researched the operational antecedents that help or inhibit the integration of planning in healthcare. They identified five different operational antecedents for integration: performance management, shared resources, information technology, process visibility, and
8 Leuschner et al. (2013) developed three different dimensions to supply chain integration (SCI) in their meta-analysis to compare and contrast the specific effects of SCI on firm performance.
“Information integration refers to the coordination of information transfer, collaborative communication and supporting technology among firms in the supply chain.”
“Operational integration refers to the collaborative joint activity development, work processes and coordinated decision making among firms in the supply chain.”
“Relational integration refers to the adoption of a strategic connection between firms in the supply chain characterized by trust, commitment and long-term orientation’’ (Leuschner et al., 2013).
In this research, we focus on the aspects of cooperation and working together of internal integration. Therefore, a relational perspective is taken. Going back to different dimensions of Leuschner et al. (2013), trust, commitment, and long-term orientation are the antecedents of relational integration. The antecedent of long-term orientation is not taken into
consideration in this research while the profession of emergency physician is still a relatively new profession in the Netherlands and a long-term orientation has probably not been
developed between the ED and other departments. Furthermore, the training to become an ED Physician in the Netherlands is still in its infancy and also still developing
(“Spoedeisende Hulp | medischcontact,” 2016). However, it has been identified that lack of these relational antecedents can form a barrier towards integration (Vijayasarathy, 2010). Furthermore, the internal integration of an organization, in general, is difficult, because changes in organizational structure as well as in incentive systems are necessary (Bowersox,
Closs, & Stank, 2000; Ventura & Giménez, 2013; Fawcett & Magnan, 2001). Competing or
9 Having found that the antecedents trust, commitment and incentive systems may form
barriers towards relational integration, these antecedents will be further discussed in detail.
Trust
In supply chain management trust is described as a critical factor that fosters commitment between partners in the supply chain (Kwon & Suh, 2004). Lack of trust among partners causes, just as in interpersonal relationships, inefficient and ineffective performance (Kwon & Suh, 2004). Having trust in a supply chain partnership results in the opposite and improves performance (Kwon & Suh, 2004). Furthermore, trust creates a better working environment for supply chain partners because it provides incentives for cooperation (Wu, Chuang, & Hsu, 2014). Trust is one of the most critical factors in strategic partnerships, and it causes the partners in the relationship to commit to the relationship (Vijayasarathy, 2010). Lack of trust in a supply chain partner is recognized as one of the problems for implementing supply chain collaboration (Barratt, 2004). Collaboration is part of the essence of supply chain integration (Zhao et al., 2010). Suter et al. (2009) state that, to have integration in healthcare,
collaboration between teams is a basic tenet. Furthermore, they describe lack of mutual trust as an important barrier to this collaboration.
Therefore, lack of trust can also be a barrier towards integration.
In this research, we use the definition of interfirm trust while the hospital is divided into different departments. The definition of interfirm trust is as follows:
“one party’s expectation that the other party can be relied on to fulfill obligations, behave predictably, and act and negotiate fairly even when the possibility of opportunism exists.” (Cai, Jun, & Yang, 2010; Zaheer & Venkatraman, 1995). When a party behaves
opportunistically, they increase their own utility at the expense of another party or the
customer (Nagin, Rebitzer, Sanders, & Taylor, 2002). One of the challenges to build trust in a relationship is commitment (Fawcett & Magnan, 2001).
Commitment
10 resource is directed explicitly to the other party in the relationship, it is referred to as an asset-specific resource (Dyer, Gupta, & Wilemon, 1999).
In this research, commitment is described as the willingness of a party to invest financial, physical or relationship-based resources in a partner in the supply chain (Morgan & Hunt, 1994; Zhao, Huo, Flynn, & Yeung, 2008).
Incentive systems
The barrier of incentive systems Bowersox et al. (2000) describe is rather interesting when looking at the integration of the emergency department and other departments in the hospital. Bowersox et al. (2000) describe that internal integration is difficult because changes in incentive systems are needed.
Glover et al. (2017) state that although hospitals try to integrate more, they have difficulty implementing it because there are no incentives for working together with other departments. Furthermore, specialists see it as taking away even more patient-provider interaction, i.e. more non-clinical tasks.
Specialists that work on an FFS basis produce a higher care volume than specialists that work on a salaried basis (Kok et al., 2010). Research done in the Netherlands showed that
specialists that work on an FFS base work, on average, 4 hours more than specialists that work on a salaried basis (Kok et al., 2010). However, this is not the only explanation for their higher care volume production, it is also because they allocate more of their time on
performing medical operations rather than on management and administrative tasks, and consultation with other specialists (Kok et al., 2010). In incentive theory, someone’s actions are directed towards gaining rewards (Douglas Jenkins Jr, Mitra, Gupta, & Shaw, 1998). This high volume of care may be useful for patient waiting times but may cause physicians to neglect other tasks, due to the high-powered incentive contract to provide a high care volume (Dumont et al., 2008).
11 work for their cooperation, the more patients that are treated by the specialist, the more profit the cooperation makes. The profit is then divided among the specialists in the cooperation. They are often in a cooperation of specialists where one or multiple specialties are united called an MSB. Several studies have shown that fee-for-service physicians have a higher care volume than salaried physicians (Dumont, Fortin, Jacquemet, & Shearer, 2008). According to Kok, Houkes, and Tempelman (2010), they do spend less time on consulting with other specialists. While consulting with other specialists is working together with them and sharing information, the incentive system could form a barrier towards integration in acute care. An initial research model has been made to clarify which barriers to internal integration have been found in literature (figure 1).
Figure 1: Initial research model
Financial incentives
Internal
integration
12
METHODOLOGY
Given that there is little known about what the barriers are to the integration of specialists within hospitals there is opted for an exploratory case study. In a situation where there is little known about a subject a case study method is justified (Eisenhardt, 1989; Yin, 2003). Semi-structured interviews were done using an interview guide which can be found in the
appendix. In total, seven doctors were interviewed, five emergency physicians and two specialists. The questionnaire used for this research can be found in the appendix. The first section consists of questions on integration, and the second section consists of questions on payment structure.
Data analysis
All interviews were recorded with the consent of the specialists. These recordings were transcribed. After transcribing all the interviews, the data was coded. The interviews were coded using Atlas.ti, software for qualitative data analysis and research, starting with an initial coding round. After the initial coding round, code structure trees and a draft model were created. This draft model will then be compared to the initial research framework and existing theories. Follow-up coding will further develop the model. The coding was done
using the Gioia method, first recognizing first order concept, then second-order themes that will
eventually make up aggregate dimensions (Gioia, Corley, & Hamilton, 2013).
In the first round of coding, 120 codes were identified. During the second round of coding 10
2nd order themes were identified which eventually made up four aggregate dimensions.
Case description
The interviews were held at Hyperion, a large, general hospital in the north of the
Netherlands. It is a clinical hospital for acute, highly complex and primary healthcare. Over 3000 people are employed at the Hyperion spreading over 500 different functions. The hospital has 48 specialties and a center for healthcare ranging from, for example,
13 They can arrive on the emergency department by just walking in there, which is called a self-referral, they can be sent to the ED by their general practitioner, they can come in after being picked up by an ambulance or they can arrive on the ED when visiting the outpatient clinic and something went wrong there. In case of a patient that is sent in via the GP, this patient is already sent in for a specific specialty, and they come to the ED because of their acuteness. In this case, a specialist decides to send a patient to the ED. Patients who are already in the hospital, for example in the outpatient clinic, can also be sent to the ED when they develop acute problems on the outpatient clinic. Patients who arrive via walk-in first see a triage nurse who determines the priority of the patient, by using color codes, based on the severity of their condition. Patients that arrive with the emergency medical services receive triage in the ambulance.
14
FINDINGS
Availability of doctors
In the interviews with the ED physicians one problem kept recurring, the availability of specialists for the ED.
The availability of specialist doctors is a problem in different steps of the process on the ED where internal integration between departments is necessary. The fact that they are a shared resource does, of course, play a role in this. ED physicians state that they have to work together with different specialties every day either asking for confirmation to admit a patient or send a patient home, or asking them to physically come to the ED to help them. This often happens over the phone.
ED Physician 4: “We work together all day long, and a lot of it goes by phone."
It is important for the ED physicians that specialists are well reachable and available. When one of the ED physicians was asked what they would like to change they answered:
ED Physician 4: “Well, what I ideally would like to have is that everybody always answers his phone directly."
The ED physicians state that it does happen that specialists do not pick up their phone and are not always well reachable.
ED Physician 4: “I would like everybody to be well reachable."
ED Physician 4: “sometimes the phone is just lying on the desk and is not with the doctor.”
The availability of specialists can be a problem because the decision whether to admit a patient or send a patient home is up to the specialist and the ED physician has to confer with him or her first. This could have consequences for the flow of the ED while a patient that is ready to be admitted can’t be admitted because of the unavailability of specialists. This patient is still keeping a bed occupied on the ED which can cause crowding.
ED Physician 5: “Sometimes people are not easy to reach because they are busy or they cannot pick up their phone, so that causes some delay and some frustrations.”
15
ED Physician 3: “you do the best you can and try to phone the operation theatre and
ask if the surgeon is there. Alternatively, you just call another surgeon who does not have the duty telephone, but you just call another one. You try to do your best.” At first glance, the reason for this unavailability appears to be an issue of shared resources. Sometimes specialists are too busy working on the outpatient clinic or doing operations or are even not willing to come to the ED.
ED Physician 1: “sometimes someone is doing an operation as well, and he or she cannot come immediately, but they are at least notified.”
ED Physician 5: “sometimes they have busy programs, and they cannot leave the operating room, or they cannot leave their outpatient clinic center."
ED Physician 4: “there are some anesthesiologists that are really not willing to come.”
Regardless of this, the unavailability of specialists is also conceived as a lack of commitment from the different specialists’ departments.
ED Physician 5: “No they are not really concerned about our issues here, we tried to get them more involved."
Furthermore, there is a call from ED physicians to have the power to admit a patient to a specific specialty when they think this particular patient belongs there without first conferring with a specialist.
ED Physician 1: “When you need to consult other specialties at the ED, before he/she can be admitted somewhere. That is a thing that we can make better.”
ED Physician 4: “I think we could be more effective if the ED physician could decide for himself if the patient needs to be admitted or not.''
In terms of integration and flow between the departments this could be a solution but it will mean that the structure of the organization has to change which as described in the theoretical
background is difficult to achieve (Bowersox, Closs, & Stank, 2000; Ventura & Giménez,
16
Commitment
In our interviews with the ED physicians, we found that it differs per specialty whether specialists are able or even willing to come to the ED. Some specialties are always able to come, but there are also specialties that never want to come to the ED and work together with the ED physicians. One of the reasons the ED physicians gave for the unavailability was that the specialists are a shared resource for the ED. For example, specialists were working in the outpatient clinic or working in the operating room making them unable to come to the ED at all or arriving late. But another reason was given too, that it is the mentality of some people. This can be seen as that ED physicians perceive that, some specialists are not willing to spend time and resources to the ED i.e. they are not committed to the ED.
ED Physician 3: “I think it is the mentality, some people are always willing to come, and some people are never able to come. They just say: I cannot come right now.”
Moreover, the ED has an arrangement with some specialties that they have to be present at the ED within 15 minutes, but it does happen that specialists arrive late, also adding to the perceived lack of commitment specialists have according to ED physicians. As said earlier, the specialists are often busy doing other things, and they cannot know when they will be needed on the ED due to the uncertainty of the ED. Nevertheless, the ED physicians think every specialist should be able to be on the ED on time.
ED Physician 3: “I think if you really want to come, you can arrange something…If you have to wait 20 minutes for a specialist. In my opinion, it is wrong.”
From this statement, we learn that the ED physicians not only think it is because of shared resources that the specialists are not able to come to the ED or answer the phone, but that they also perceive it as a lack of commitment when specialists arrive late, or do not arrive, at the ED.
Moreover, one of the specialists stated that the ED was never that important to them, that they never had somebody scheduled to be available for the ED and that they did not take good care of the ED because they would be busy doing other things.
Specialist 2: “the emergency department was never, apparently never that important, just something cumbersome thing that also happens…We did not take care of the emergency department."
17 The lack of commitment some of the specialties have do affect the internal integration
between departments. Cooperation and working together is not done timely or is not done at all. The organization and specialists, however, have recognized this as a key issue, and as a result of this, recently a test trial was started in this hospital. During this trial, a doctor from a specific specialty department will be present at the ED during the busiest time of the day, which is the afternoon. To start with the trial was the decision of the specialist department that is now going to be physically present on the ED. However, although the ED physicians wanted specialists’ departments to be more involved in the ED, it seems like they do not fully support the decision of the specialist department to have a specialist present on the ED. What the ED specialists wanted, was to get the specialists more involved and committed to the ED to solve problems with flow on the ED. The ED physicians started by asking the specialists how the flow of patients in the ED could be improved and a specific specialty department came up with an idea to have a specialist on the ED during the busiest hours. In other words, one specialty department committed resources to the ED with now one specialist being an asset-specific resource during the busiest hours instead of a shared resource.
According to the specialist, it seemed like the test trial was already improving performance on the ED.
Specialist 2: “turnover times are much better and generally what you would expect, that decisions are made earlier. The decision to admit a patient, or the decision to send a patient home without further diagnostics.”
On the contrary, the ED physicians were skeptical about the motives of the specialist department and state it was not their call to have a specialist present on the ED.
ED Physician 5: “that was their call to introduce this as a solution."
ED Physician 3: “If you ask me honestly, it is not on our suggestion that they are coming here.”
The ED physicians think the decision to put this certain specialist on the ED is not only to improve the performance of the ED but that there is also a financial incentive.
ED Physician 3: “It all has something to do with money. However, that is very complicated.”
ED Physician 5: “Is there a second agenda? ... Is it about money?”
18 The perceived financial incentive comes forth from the different payment structures while ED physicians are salaried by the hospital, many specialists are in a cooperation where they receive their income based on the production of their group.
Incentives
Specialists that are in a cooperation who receive their income based on the production of their group do have this financial incentive to produce more care. This also shows from our
interviews. ED physicians stated that there is definitely a difference between the two groups regarding production and that there is a financial incentive for doctors working in a
cooperation:
ED Physician 2: “Here it is going, going, going. See more patients, and it really goes faster because the more they do, the more income they have and the more money they get from the insurance companies every year.”
ED Physician 2:” They are willing to work harder and see more patients…that is why they want to see many patients then they will get more money also."
ED Physician 6: “you are self-employed, so if they see more patients they get more money, so that is a financial motivation."
The ED physicians like being salaried because then they do not have to think about money. This also points in the direction that the ED physicians do think that specialists working on a FFS basis care more about money.
ED Physician 5: “No I like this because then I do not have a financial motivation.” ED Physician 3: “Well for me personally I really like being employed in the hospital because I do not have to think about money. I can just do what I think is the best for the patient."
In line with the previous statement, the salaried specialist we interviewed also rather focusses on his primary task as a doctor and states that specialists in a cooperation always talk about money indicating that they sometimes do not focus on their primary task as a doctor.
19 Moreover, ED physicians think that having a financial incentive is not always best for patient care.
ED Physician 1: “They get paid by the number of patients they see. There are a lot of mandatory things to attend which are not directly patient related.”
ED Physician 4: “The financial item that is now included, it does not always go in the same direction as what is best for patient care or efficiency.”
The previous statements indicate that salaried doctors might think that specialists in
cooperation sometimes put their financial interests in front of what is best for the patient. In a situation where the financial incentive is put above what is best for the patient, overtreatment might take place. Furthermore, the ED physicians would rather see every specialist working on a salaried basis.
ED Physician 3: “I would really like all the specialists to be in duty of the hospital. I think that would make so many things so much easier.”
ED Physician 4: “I think it makes things a lot easier when there is one payment structure, that doctors do not have to think about how the gain the most money for their business, for their department.”
20
Trust
From our interviews, we can conclude that the ED physicians do not always trust the motives of specialists. They think that the specialists do not always act in a way that is the best for the patient. They do not think the quality of care the specialists provide is worse or less but that it makes things more complicated, also on the ED.
ED Physician 3: “Well for me personally I really like being employed in the hospital because I do not have to think about money. I can just do what I think is the best for the patient.”
ED Physician 3: “They always say they want to go for quality, but we know there is a background agenda, and we doubt often, is this really about quality or do they hope they are getting more money for this. I do not mean it nasty... but that is how it works I think in the world.”
Although the ED physicians have a lack of trust towards the motives of the specialist department, it does not seem to form a barrier towards integration. The ED physicians are still willing to work together more intensively because they see the potential improvements this test trial can bring along.
ED Physician 5: “We really have to see how it works and if it really results in better throughput times or is it just another person on the floor.”
ED Physician 5: “I have an open view, and we will see. Because I also see the potential for quality improvements.”
21
DISCUSSION
In the results, we find that in the uncertain environment of the ED shared resources are, in line with theory, indeed a barrier towards internal integration while specialists were
sometimes unavailable to work together, share information and collaborate with emergency physicians because the specialists were too busy doing their job on their own department. As stated by Van Donk and Van Der Vaart (2005) that in situations where there is high uncertainty, shared resources make it more challenging to reach close cooperation and integration. Uncertainty and shared resources were identified as inhibitors of integration in healthcare (Drupsteen et al., 2016), from our findings we can see that this is also the case for acute care. Interestingly, the ED physicians, while well aware of the fact that specialists are a shared resource for the ED, do also feel that some specialists lack commitment to the ED.
Commitment
As explained in the theoretical background, specialists do not only work on their own
department, but they also often have to work together with the ED, whether it is for admitting a patient or going to the ED to help with a patient, which makes them a shared resource. Shared resources make it harder to closely cooperate and integrate which is critical to do in case of high levels of uncertainty (Van Donk & Van Der Vaart, 2005). From our results, we see that shared resources, also in acute care, do form a barrier towards integration and working together while specialists were, according to the ED physicians, sometimes busy with other things and were unavailable to either share information with them or to come to the ED and work together. Although the emergency physicians were aware of the shared resources, they did perceive that some specialists had a lack of commitment to the ED regardless of the shared resources. According to the ED physicians, this is frustrating and sometimes causes delays. Most specialists are willing to go to the ED if they have time, but they are not willing to commit resources to it, in this case having some of their time
scheduled to go to the ED. Although specialists are willing to go to the ED and help out, it seems like it is not their priority. Research shows us that when someone has the willingness to do something, the step to convert this willingness into activities is moderated by situational stimuli and barriers (Montada & Kals, 1998). It is interesting that the ED physicians perceive that not only the fact that specialists are a shared resource is the reason for the lack of
22 mentality. From our interviews with the specialists we learn that they were indeed too busy doing their own job and would not have time to commit resources to the ED.
Not being able to share information timely and work together effectively is not only bad for integration between two departments but could also have severe consequences on the ED (Cheung et al., 2010). Furthermore, the test trial in the hospital is the perfect example of not having shared resources and having commitment to another department. In the test trial, a specialist from a specific department is no longer a shared resource and is fully committed to the emergency department which is already improving performance, according to the
specialist, due to better integration. Decisions to admit patients are taken earlier and consultations can be done much faster. In other words,
This further expands the theory that shared resources and commitment form barriers towards integration. Therefore, we keep commitment as a barrier towards internal integration in our revised model.
Incentive systems and trust
From our results, we can conclude that the financial incentive that was sketched in the theoretical background does also exist among specialists, in our case study. Specialists that work on a FFS basis have, according to the ED physicians, a financial incentive to produce more care. This corresponds to the research of Kok et al. (2010) stating that doctors working in a cooperation produce a higher care volume than salaried doctors. This research studies the barriers towards internal integration. Although in literature it was stated that specialists working in a cooperation spend less time on non-clinical tasks, including consultations with other doctors, but no clear statements were made that this was attributable to the financial incentive of specialists. However, we did find that specialists in cooperations were sometimes unavailable to consult or work together on the ED because they were busy in the operating room, or working on the outpatient clinic, which is their clinical task and where money is earned, but it was not clear whether they were unavailable to work together because of their financial incentive. Furthermore, it was also stated by the ED physicians that because of these financial incentives, they have the idea that patient care is not always the priority of
23 say that they make their decisions regarding patient not based on financial rewards,
overtreatment does exist and that financial incentives do influence the behavior of medical specialists (Korenstein, Falk, Howell, Bishop, & Keyhani, 2012; Paxton et al., 2012 IN Green, 2014). While this research is concerning the internal integration between the emergency department and other departments looking at the relational antecedents, strong implications were found that salaried doctors do not fully trust doctors in cooperations because of their financial incentives. The salaried doctors think that because of the financial incentive other doctors have, that not always everything is patient related, best for the patient or best for the efficiency of the hospital. When we go back to our definition of interfirm trust; “one party’s expectation that the other party can be relied on to fulfill obligations, behave predictably, and act and negotiate fairly even when the possibility of opportunism exists.” (Cai, Jun, & Yang, 2010; Zaheer & Venkatraman, 1995) the ED physicians do not expect that FFS specialists act fairly and think that they behave opportunistically i.e. there is a
misalignment in incentives. The finding that this financial incentive of doctors in
24
CONCLUSION AND LIMITATIONS
In this research, the barriers to internal integration were explored in the acute care setting. From our findings, we can conclude that commitment can form a barrier towards internal integration in the acute care setting. We also found that internal integration in acute care is an issue. Sharing information, cooperation and working together could be improved between the emergency department and other specialist departments in the hospital. Furthermore, we found a new relationship where the incentives of doctors in a cooperation can form a lack of trust in salaried doctors. Because lack of trust can form a barrier to integration, as is known from previous studies and our theoretical background, the misalignment in incentives between the salaried ED physicians indirectly forms a barrier towards integration.
This is an interesting relationship that should be further studied. In further research, the view of the specialists working in a cooperation should be more incorporated to explore this topic in more detail. Overall, this research has further explored the topic of integration in
healthcare, which is scarce in literature (Drupsteen et al., 2013). Furthermore, the call from crowding literature to investigate integration in acute care has been answered (Hoot & Aronsky, MD, 2008).
Limitations
25
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31
APPENDIX
Questionnaire
Demographics: Age:_____ Tenure:_____ Gender:_____ Hours: ___
1. Can you tell me your role (and specialty)?
2. How many hours do you work per week? (on average)
3. What motivates you in your work? What is most important to you? 4. How did you end up at this particular hospital?
Internal Integration and handovers 1. Who are working at the ED now?
a. What are their roles?
2. How often do you work together with other specialists/ED physicians? a. Do you like working together with the ED physicians/specialists? 3. In what way do you work together with the ED/specialties?
a. Information sharing/consults? b. Handovers?
i. How do handovers work between the ED and wards?
ii. Who is involved?
4. Do you feel like (when needed) you work well together with the ED/wards? a. during information sharing/consults
b. during handovers
5. Do you ever experience any issues working together? a. during information sharing/consults
b. during handovers? Barriers? c. Would you change anything?
6. Do you feel that you have enough time to engage in these kind of activities? a. Do your colleagues feel the same about this?
b. ED physicians?
7. Are there guidelines provided by the hospital or the cooperation on how to collaborate with different specialties/ED? (formal/informal process?)
a. Is there a formal process for handovers? And is it used?
i. Who made it and why?
ii. How do you feel about this process?
iii. Do you get trained in this?
b. Are there formal routines and procedures in place to coordinate integration between specialties/ED?
8. Can you tell me about the new structure you are trying? a. Do you like it?
b. What is changing?
c. What are problems arising?
9. Do the goals of different specialties always align? (ED and department) a. Do payment systems contribute to this mis/alignment?
b. Do you notice any differences between salaried and self-employed specialists?
32 physicians?
d. Do they spend more or less time on handovers?
10. Does your specialty freely exchange information with other specialties/ED? a. Has everyone access to the patient records?
11. Is there a hierarchy between doctors?
12. Is it always clear who to contact at other specialists and how do you know this?
13. Do you have to wait for specialists?
14. Do you notice differences in how specialists collaborate with the ED? 15. Do interdepartmental meetings take place in the hospital?
a. Why do they take place?
b. How and by whom is it organized? c. How often?
d. Which specialities? e. What is discussed? Performance
1. Do you think that the collaboration between the ED and specialists have an influence on patient flow?
a. In what way?
b. Do you have an example? Organizational structure:
1. Are you an employee of the hospital or self-employed? 2. Did you choose this payment? Why?
3. How is it organized/ distributed?
a. Tied to any performance/ activity? (e.g. Is your pay dependent on any output (so per DOT, DBC)
b. Does it influence how you work?
4. What would you say are the advantages and disadvantages of each model? 5. Are you colleagues (within specialty) all on same payment?
a. Other specialties?
6. Do you think it work to have more than one payment system for doctors? (In same hospital)
7. Do you think pay affects motivation? a. Can you give an example of this? b. Why does it make you feel that way?
8. Do you notice any difference in how specialists in different employment models work?
