The theory and practice of integrative health care governance: The case of New Zealand’s alliances

Key elements and contextual factors that influence successful implementation of large-system transformation initiatives in the New Zealand health system: a realist evaluation

BACKGROUND

Despite three decades of policy initiatives to improve integration of health care, delivery of health care in New Zealand remains fragmented, and health inequities persist for Māori and other high priority populations. An evidence base is needed to increase the chances of success with implementation of large-system transformation (LST) initiatives in a complex adaptive system.

METHODS

This research aimed to identify key elements that support implementation of LST initiatives, and to investigate contextual factors that influence these initiatives. The realist logic of enquiry, nested within the macro framing of complex adaptive systems, formed the overall methodology for this research and involved five phases: theory gleaning from a local LST initiative, literature review, interviews, workshop, and online survey. NVivo software programme was used for thematic analysis of the interview, workshop, and the survey data. We identified key elements and explained variations in success (outcomes) by identifying mechanisms triggered by various contexts in which LST initiatives are implemented.

RESULTS

The research found that a set of 10 key elements need to be present in the New Zealand health system to increase chances of success with implementation of LST initiatives. These are: (i) an alliancing way of working; (ii) a commitment to te Tiriti o Waitangi; (iii) an understanding of equity; (iv) clinical leadership and involvement; (v) involved people, whānau, and community; (vi) intelligent commissioning; (vii) continuous improvement; (viii) integrated health information; (ix) analytic capability; and (x) dedicated resources and time. The research identified five contextual factors that influenced implementation of LST initiatives: a history of working together, distributed leadership from funders, the maturity of Alliances, capacity and capability for improvement, and a continuous improvement culture. The research found that the key mechanism of trust is built and nurtured over time through sharing of power by senior health leaders by practising distributed leadership, which then creates a positive history of working together and increases the maturity of Alliances.

DISCUSSION

Two authors (KMS and PBJ) led the development and implementation of the local LST initiative. This prior knowledge and experience provided a unique perspective to the research but also created a conflict of interest and introduced potential bias, these were managed through a wide range of data collection methods and informed consent from participants. The evidence-base for successful implementation of LST initiatives produced in this research contains knowledge and experience of senior system leaders who are often in charge of leading these initiatives. This evidence base enables decision makers to make sense of complex processes involved in the successful implementation of LST initiatives.

CONCLUSIONS

Use of informal trust-based networks provided a critical platform for successful implementation of LST initiatives in the New Zealand health system. Maturity of these networks relies on building and sustaining high-trust relationships among the network members. The role of local and central agencies and the government is to provide the policy settings and conditions in which trust-based networks can flourish.

OTHER

This study was approved by the Victoria University of Wellington Human Ethics Committee (Ethics Approval Number 27,356). The research was supported by the Victoria University of Wellington research grant (222,809) and from the University of Auckland Department of Medicine research fund (H10779).

Family physicians partnering for system change: a multiple-case study of Ontario Health Teams in development

BACKGROUND

The Ontario Health Team (OHT) model is a form of integrated care that seeks to provide coordinated delivery of care to communities across Ontario, Canada. Primary care is positioned at the heart of the OHT model, yet physician participation and representation has been severely challenged at planning and governance tables. The purpose of this multiple case study is to examine (1) processes and structures to enable family physician participation in OHTs and (2) describe challenges to family physician participation.

METHODS

We chose a qualitative, exploratory multiple-case study approach following Yin's design and methods. The study took place between June and December 2021.We conducted semi-structured interviews with OHT stakeholders in four communities and carried out an analysis of internal and external documents to contextualize interview findings. Thematic analysis was applied within case and between cases.

RESULTS

Four OHTs participated in this study with thirty-nine participants (17 family physicians; 22 other stakeholders). Over 60 documents were analyzed. Within-case analysis found that structures and processes should be formalized and established to facilitate physician participation. Skepticism, burnout, heavy workload, and the COVID-19 pandemic were challenges to participation. Between-case analysis found that participation varied. Face-to-face communication processes were favoured in all cases and history of collaboration facilitated relationship-building. All cases faced similar challenges to physician participation despite regional differences.

CONCLUSIONS

The implementation of OHTs demonstrates that integrated care models can address critical health system issues through a collective approach. Physician participation is vital to the development of an OHT, however, recognition of their challenges (skepticism, burnout, COVID-19 pandemic) to participating must be acknowledged first. To ensure that models like OHTs thrive, physicians must be meaningfully engaged in various aspects and levels of governance and delivery.

Study on the evolutionary strategy of upward patient transfer in the loose medical consortia

Medical institutions in loose medical consortia tend to have poor cooperation due to fragmented interests. We aim to explore any issues associated with patient upward transfer in a loose medical consortium system consisting of two tertiary hospitals with both cooperative and competitive relationships. A two-sided evolutionary game model was constructed to assess the stability of equilibrium strategy combinations in the process of interaction between game players under different cost-sharing scenarios and different degrees of penalties when running patient upward transfer between super triple-A hospitals (STH) and general triple-A hospitals (GTH). We found that a hospital's stabilization strategy was related to its revenue status. When a hospital has high/low revenues, it will treat patients negatively/positively, regardless of the strategy chosen by the other hospital. When the hospital has a medium revenue, the strategy choice will be related to the delay cost, delay cost sharing coefficient, government penalty and the strategic choice of the other hospital. Delay cost-sharing coefficient is an important internal factor affecting the cooperation in a medical consortium for patient upward transfer. External interventions, such as government penalty mechanisms, can improve the cooperation between hospitals when hospitals have moderate revenue.

A realist approach to understanding alliancing within Local Government public health and social care service provision

BACKGROUND

Within the current context of continued austerity and post-pandemic recovery, it remains important that Local Government services address the increasing needs of residents as cost-effectively as possible. Alliancing, whereby services work collaboratively focusing on the 'whole-system', has gained popularity as a tool with the potential to support collaborative whole systems approaches. This synthesis aims to identify how alliancing can be successfully operationalised in the commissioning of public health, wider National Health Service (NHS) and social care-related services.

METHODS

A realist literature synthesis was undertaken in order to identify underlying generative mechanisms associated with alliancing, the contextual conditions surrounding the implementation and operationalisation of the alliancing approach mechanisms, and the outcomes produced as a result. An iterative approach was taken, using a recent systematic review of the effectiveness of Alliancing, online database searches, and grey literature searches.

RESULTS

Three mechanistic components were identified within the data as being core to the successful implementation of alliances in public health and social care-related services within Local Government: (i) Achieving a system-level approach; (ii) placing local populations at the heart of the system; and (iii) creating a cultural shift. Programme theories were postulated within these components.

CONCLUSIONS

The alliancing approach offers an opportunity to achieve system-level change with the potential to benefit local populations. The realist synthesis approach taken within this study has provided insights into the necessary contextual and mechanistic factors of the Alliancing approach, above and beyond effectiveness outcomes typically collected through more conventional evaluation methodologies.

Lessons learnt from the implementation of new models of care delivery through alliance governance in the Southern health region of New Zealand: a qualitative study

OBJECTIVES

To explore the process of implementation of the primary and community care strategy (new models of care delivery) through alliance governance in the Southern health region of New Zealand (NZ).

DESIGN

Qualitative semistructured interviews were undertaken. A framework-guided rapid analysis was conducted, informed by implementation science theory-the Consolidated Framework for Implementation Research.

SETTING

Southern health region of NZ (Otago and Southland).

PARTICIPANTS

Eleven key informants (Alliance Leadership Team members and senior health professionals) who were involved in the development and/or implementation of the strategy.

RESULTS

The large number of strategy action plans and interdependencies of activities made implementation of the strategy complex. In the inner setting, communication and relationships between individuals and organisations were identified as an important factor for joint and integrated working. Key elements of a positive implementation climate were not adequately addressed to better align the interests of health providers, and there were multiple competing priorities for the project leaders. A perceived low level of commitment from the leadership of both organisations to joint working and resourcing indicated poor organisational readiness. Gaps in the implementation process included no detailed implementation plan (reflected in poor execution), ambitious targets, the lack of a clear performance measurement framework and an inadequate feedback mechanism.

CONCLUSIONS

This study identified factors for the successful implementation of the PCSS using an alliancing approach in Southern NZ. A key enabler is the presence of a stable and committed senior leadership team working through high trust relationships and open communication across all partner organisations. With alliances, partnerships and networks increasingly held up as models for integration, this evaluation identifies important lessons for policy makers, managers and services providers both in NZ and internationally.

An integrative perspective on interorganizational multilevel healthcare networks: a systematic literature review

BACKGROUND

Interorganizational networks in healthcare do not always attain their goals. Existing models outline the factors that could explain poor network performance: governance; structure; and the alignment of professional, organizational and network levels. However, these models are very generic and assume a functional approach. We investigate available empirical knowledge on how network structure and governance relate to each other and to network performance in a multilevel context, to get deeper insight, supported with empirics, of why networks (fail to) achieve their goals.

METHOD

A systematic literature review based on a search of Web of Science, Business Source Complete and PubMed was executed in May 2021 and repeated in January 2022. Full papers were included if they were written in English and reported empirical data in a healthcare interorganizational setting. Included papers were coded for the topics of governance, structure, performance and multilevel networks. Papers from the scientific fields of management, administration and healthcare were compared. Document citation and bibliographic coupling networks were visualized using Vosviewer, and network measures were calculated with UCINET.

RESULTS

Overall, 184 papers were included in the review, most of which were from healthcare journals. Research in healthcare journals is primarily interested in the quality of care, while research in management and administration journals tend to focus on efficiency and financial aspects. Cross-citation is limited across different fields. Networks with a brokered form of governance are the most prevalent. Network performance is mostly measured at the community level. Only a few studies employed a multilevel perspective, and interaction effects were not usually measured between levels.

CONCLUSIONS

Research on healthcare networks is fragmented across different scientific fields. The current review revealed a range of positive, negative and mixed effects and points to the need for more empirical research to identify the underlying reasons for these outcomes. Hardly any empirical research is available on the effects of different network structures and governance modes on healthcare network performance at different levels. We find a need for more empirical research to study healthcare networks at multiple levels while acknowledging hybrid governance models that may apply across different levels.

Overwriting New Public Management with New Public Governance in New Zealand's approach to health system improvement

Purpose

In 2016, New Zealand's Ministry of Health introduced the System Level Measures Framework which marked a departure from health targets and pay-for-performance incentives towards an approach based on local, collaborative approaches to health system improvement. This exemplifies an attempt to “overwrite” New Public Management (NPM) institutional practices with New Public Governance (NPG). We aim to trace this process of overwriting so as to understand how attempts to change institutional practices were facilitated, blocked, translated and edited.

Design/methodology/approach

We develop a conceptual framework for understanding and tracing institutional change towards NPG which emphasises the importance of discursive strategies in policy attempts to overwrite NPM with NPG. To analyse the New Zealand case, we drew on policy documents and interviews conducted in 2017–18 with twelve national key informants and fifty interviewees closely involved in local development and/or implementation of the SLMF.

Findings

Policy sponsors of collaborative approaches to health system improvement first attempted formal institutional change, arguing that adopting collaborative, quality improvement (NPG) approaches would supplement existing performance management (NPM) practices, to create a superior synthesis. When this formal approach was blocked, they adopted an approach based on informal persuasion of local organisational actors that quality improvement should supplant performance improvement. This approach was edited and translated by local actors, and the success of local implementation varied considerably.

Research limitations/implications

This article offers a novel conceptualisation of public management institutional change, which can help explain why it is difficult to completely erase NPM practices in health.

Originality/value

This paper explores the rhetorical practices that are used in the introduction of a New Public Governance policy framework.

Did healthcare professional perspectives on the quality and safety environment in New Zealand public hospitals change from 2012 to 2017?

PURPOSE

The work environment is known to influence professional attitudes toward quality and safety. This study sought to measure these attitudes amongst health professionals working in New Zealand District Health Boards (DHBs), initially in 2012 and again in 2017.

DESIGN/METHODOLOGY/APPROACH

Three questions were included in a national New Zealand health professional workforce survey conducted in 2012 and again in 2017. All registered health professionals employed with DHBs were invited to participate in an online survey. Areas of interest included teamwork amongst professionals; involvement of patients and families in efforts to improve patient care and ease of speaking up when a problem with patient care is perceived.

FINDINGS

In 2012, 57% of respondents (58% in 2017) agreed health professionals worked as a team; 71% respondents (73% in 2017) agreed health professionals involved patients and families in efforts to improve patient care and 69% (65% in 2017) agreed it was easy to speak up in their clinical area, with none of these changes being statistically significant. There were some response differences by respondent characteristics.

PRACTICAL IMPLICATIONS

With no change over time, there is a demand for improvement. Also for leadership in policy, management and amongst health professionals if goals of improving quality and safety are to be delivered upon.

ORIGINALITY/VALUE

This study provides a simple three-question method of probing perceptions of quality and safety and an important set of insights into progress in New Zealand DHBs.

New Zealand's Integration-Based Policy for Driving Local Health System Improvement - Which Conditions Underpin More Successful Implementation?

Introduction:

The System Level Framework (SLMF) is a policy introduced by New Zealand’s Ministry of Health in 2016 with the aim of improving health outcomes by stimulating inter-organisational integration at the local level. We sought to understand which conditions that vary at the local level are most important in shaping successful implementation of this novel and internationally significant policy initiative relevant to integrated care.

Strategy and Methods:

We conducted 50 interviews with managers and clinicians who were directly involved in SLM implementation during 2018. Interview data was supplemented with the SLM Improvement Plans of all districts over the first three years of implementation. We used Qualitative Comparative Analysis (QCA) to identify the combinations and configurations of necessary and sufficient conditions of successful implementation.

Results:

We found that the strength of formal and informal organisational relationships at the local level were critical conditions for implementation success, and that while fidelity to the policy programme was necessary, it was not sufficient. Broader contextual features such as population size and complexity of the organisational environment were less important. The SLMF was able to deepen and widen inter-organisational collaboration where it already existed but could not mitigate the legacies of weaker relationships.

Discussion:

The two dimensions of implementation success, ‘Maturity of SLM Improvement Plan Processes’ and ‘Data Sophistication and Use’ were closely related. Broadly, our findings support the contention that integrated approaches to health system improvement at the local level require collaborative, trust-based approaches with an emphasis on iterative learning, including the willingness to share data between organisations.

Conclusion:

In the context of integrated care, our findings support the need to focus on establishing the conditions that build collaborative governance in addition to strengthening it when it already exists.

What components are important for effective healthcare alliance governance? Findings from a modified Delphi study in New Zealand

Alliance governance is a form of governance developed in industry settings and more recently applied to healthcare. The core idea behind alliance governance is to involve the many stakeholders in the system to collaboratively develop a joint programme that promotes an integrated and whole of systems approach to care. Little is known about the model in healthcare, nor what those involved in an alliance should be focused upon. Using a modified Delphi method, this research presents a set of components that research participants agreed should underpin development of an effective alliance governance arrangement. These characteristics include a systems perspective-a truly shared governance protocol based on a shared vision and a common purpose; performance measurement-collecting and using real-time data that depicts the realities of an end-to-end system to establish better and more achievable goals based on alliance performance; a relational perspective to promote trust, respect and collaboration amongst alliance members, who historically have been competing for contracts and resources; structural changes that enable and promote a shared governance system; and, finally, equity and inclusion to ensure a diverse alliance which promotes diversity of ideas, and involvement of all stakeholders in the decision making process. This research is relevant to policymakers seeking to develop effective alliance-type arrangements as well as to those involved in the practice of alliance governance.

Are patients ready for integrated person-centered care? A qualitative study of people with epilepsy in Ireland

The National Clinical Programme for Epilepsy (NCPE) in Ireland aims to deliver a holistic model of integrated person-centered care (PCC) that addresses the full spectrum of biomedical and psychosocial needs of people with epilepsy (PwE). However, like all strategic plans, the model encompasses an inherent set of assumptions about the readiness of the environment to implement and sustain the actions required to realize its goals. In this study, through the lens of PwE, the Irish epilepsy care setting was explored to understand its capacity to adopt a new paradigm of integrated PCC. Focus groups and semi-structured one-to-one interviews were employed to capture the qualitative experiences of a sample of Irish PwE (n = 27) in the context of the care that they receive. Participants were from different regions of the country and were aged between 18 and 55 years with 1 to 42 years since diagnosis (YSD). Highlighting a gap between policy intent and action on the ground, findings suggest that patient readiness to adopt a new model of care cannot be assumed. Expectations, preferences, behaviors, and values of PwE may sustain the more traditional constructions of healthcare delivery rather than the integrated PCC goals of reform. These culturally constituted perceptions illustrate that PwE do not instinctively appreciate the goals of healthcare reform nor the different behavior expected from them within a reformed healthcare system. Recalibrating deep-rooted patient views is necessary to accomplish the aspirations of integrated PCC. Patient engagement emphasizing the meaningful role that they can play in shaping their healthcare services is vital.

Igniting intersectoral collaboration in chronic disease management: a participatory action research study on epilepsy care in Ireland

Models of care developed to improve the lives of people with chronic diseases highlight integrated care as essential to meeting their needs and achieving person (patient)-centered care (PCC). Nevertheless, barriers to collaborative practice and siloed work environments persist. To set in motion some groundwork for intersectoral collaboration this study brought two expert groups of epilepsy care practitioners together to engage in participatory action research (PAR). The expert practitioner groups were hospital-based epilepsy specialist nurses (ESNs) and community-based resource officers (CROs). The PAR highlighted, that while the participants share a mutual interest in caring for people with epilepsy, underdeveloped CRO-ESN relationships, arising from unconscious bias and ambiguity can result in missed opportunities for optimal care coordination with consequent potential for unnecessary replication and waste of finite resources. However, through dialogue and critical self-reflection, a growing emotional connection between the disciplines evolved over the course of the PAR. This allowed for buds of collaboration to develop with CROs and ESNs working together to tackle some of the key barriers to their collaboration.

Understanding the diversity of alliance governance in OECD healthcare settings

Purpose

Healthcare alliances are a mechanism for developing collaborative and integrated care governance and service delivery arrangements. Yet is not known how widespread alliance arrangements are in Organisation for Economic Co-operation and Development (OECD) countries, how alliances function or how effective they are. The purpose of this paper is to provide an overview of alliances in OECD countries, including key areas covered and how performance is measured.

Design/methodology/approach

A structured narrative review of literature published between 2010 and 2018 was undertaken, focussed on OECD countries. The literature included peer-reviewed articles as well as publications from key policy analysis organisations.

Findings

Many OECD countries have implemented integrated care models but only a small number had explicitly adopted health alliances that link primary and secondary providers under joint governance arrangements. Most alliances are pilot initiatives and not broadly adopted. Most had not adopted a unified performance measurement framework.

Practical implications

Policy makers and service providers interested in joint governance arrangements that support integration must consider the range of potential options overviewed in this paper, as well as how to create supportive performance measurement frameworks.

Originality/value

This is the first narrative review of alliance arrangements in OECD countries. It provides an overview of arrangements, while illustrating that there is considerable scope for further alliance development.

The evolution of New Zealand's health workforce policy and planning system: a study of workforce governance and health reform

INTRODUCTION

While considerable attention has been given to improving health workforce planning practice, few articles focus on the relationship between health workforce governance and health reform. By outlining a sequence of health reforms, we reveal how New Zealand's health workforce governance and practices came under pressure, leading to a rethink and the introduction of innovative approaches and initiatives.

CASE DESCRIPTION

New Zealand's health system was quite stable up to the late 1980s, after which 30 years of structural and system reform was undertaken. This had the effect of replacing the centralised medically led health workforce policy and planning system with a market-driven and short-run employer-led planning approach. The increasing pressures and inconsistencies this approach produced ultimately led to the re-centralisation of some governance functions and brought with it a new vision of how to better prepare for future health needs. While significant gain has been made implementing this new vision, issues remain for achieving more effective innovation diffusion and improved integrated care orientations.

DISCUSSION AND EVALUATION

The case reveals that there was a failure to consider the health workforce in almost all of the reforms. Health and workforce policy became increasingly disconnected at the central and regional levels, leading to fragmentation, duplication and widening gaps. New Zealand's more recent workforce policy and planning approach has adopted new tools and techniques to overcome these weaknesses that have implications for the workforce and service delivery, workforce governance and planning methodologies. However, further strengthening of workforce governance is required to embed the changes in policy and planning and to improve organisational capabilities to diffuse innovation and respond to evolving roles and team-based models of care.

CONCLUSION

The case reveals that disconnecting the workforce from reform policy leads to a range of debilitating effects. By addressing how it approaches workforce planning and policy, New Zealand is now better placed to plan for a future of integrated and team-based health care. The case provides cues for other countries considering reform agendas, the most important being to include and consider the health workforce in health reform processes.

The rhetoric and reality of integrated patient-centered care for healthcare providers: An ethnographic exploration of epilepsy care in Ireland

In line with healthcare reform across the world, the National Clinical Programme for Epilepsy (NCPE) in Ireland describes a model that aims to achieve holistic integrated person (patient)-centered care (PCC). While generally welcomed by stakeholders, the steps required to realize the NCPE ambition and the preparedness of those involved to make the journey are not clear. This study explored the perceptions of healthcare providers in the Irish epilepsy care ecosystem to understand their level of readiness to realize the benefits of an integrated PCC model. Ethnographic fieldwork including observations of different clinical settings across three regions in Ireland and one-to-one interviews with consultant epileptologists (n = 3), epilepsy specialist nurses (n = 5), general practitioners (n = 4), and senior healthcare managers (n = 3) were conducted. While there is a person-centered ambiance and a disposition toward advancing integrated PCC, there are limits to the readiness of the epilepsy care environment to fully meet the aspirations of healthcare reform. These are the following: underdeveloped healthcare partnerships;, poor care coordination;, unintended consequences of innovation;, and tension between pace and productivity. In the journey from policy to practice, the following multiple tensions collide: policy aims to improve services for all patients while simultaneously individualizing care; demands for productivity limit the time and space required to engage in incremental and iterative improvement initiatives. Understanding these tensions is an essential first step on the pathway to integrated PCC implementation.

Healthcare accreditation as trigger of organisational change: The view of professionals

BACKGROUND

Healthcare accreditation seeks to promote the organisational change in healthcare organisations from an approach that values the level of progress achieved through a validated reference framework. The aim of this paper is to analyse the role played by accreditation through the experience perceived by health professionals during the process of self-assessment and external evaluation, taking into account three dimensions of analysis: focus on the patient, internal organisation and leadership, and impact on the clinical aspects of healthcare.

MATERIAL AND METHODS

Design: Semi-structured interviews with key informants from clinical management units (CMU) within the Andalusian Health System (Spain).

PARTICIPANTS

The key informants in each CMU were the clinical leader, the head of nursing and two health professionals (doctors and nurses). A qualitative research protocol was employed to conduct the semi-structured interviews (n=52 interviews) with physicians and nurses, in order to analyse their experience with the accreditation process.

RESULTS

The analysis identified four main outcomes related to the accreditation process perceived by professionals: (1) A benchmarking conceptualisation of the process; (2) Improvements in patient-centred care, quality of clinical records, and organisational culture of the units; (3) Improvement of patient safety culture; (4) As negative outcomes, a slight perception of bureaucratisation and standardisation of the clinical practice.

CONCLUSIONS

The described initiative of accreditation process in Andalusia (Spain) is widely perceived as positive by health professionals since it fosters the organisational change, although it also has a slightly negative bureaucratisation effect on clinical practice.

Reshaping public hospitals: an agenda for reform in Asia and the Pacific

Hospitals in the Asia-Pacific today face the 'triple aim' challenge, proposed by the Institute for Healthcare Improvement, of how to improve quality of care and population health, while at the same time controlling healthcare costs. Yet, pursuing these challenges in combination is presently a remote prospect for many hospitals and, indeed, in a majority of countries in the region. The roles and functions of the public hospital sector within local health systems need redefinition and reform in the context of demographic and epidemiological transitions. Policymakers, managers and health professionals have an obligation to reshape the future of public hospitals. This article outlines actions for how public hospitals can be reshaped from a health system perspective. First, hospitals should be integrated into the fabric of the local health system; they can lead in this through working in alliances with other healthcare facilities, including primary care and private hospitals. Policymakers have a role in facilitating this as it contributes to health improvement of the population. Second, investments in system innovation, management improvement and information systems are required and their impact assessed. Such investments can contribute to cost control and efficiency. Public hospital sector investments should be strategic, efficient and should not bias investment in broader determinants of health. Third, reorienting health workforce competencies and appropriate skills should be central to hospital sector reforms, from policy to frontline services delivery. Creative thinking is needed to build and support flexible care delivery arrangements for services designed to respond to patients ' and providers' needs. Pivotal to achievement of each of these three areas of reform is good governance and leadership.