Background
Methods
Study design
Theoretical background
Clinical integration refers to the coherence in the primary process of care delivery to individuals. It requires a person-focused perspective and includes the aspect of the clients as co-creators in the care process and shared responsibility between professional and client. |
Professional integration refers to partnerships between professionals both within and between organisations. These partnerships can be characterised as forms of horizontal and/or vertical integration. To deliver a comprehensive continuum of care, professionals have to share accountability, problem solving and decision-making. As a consequence of this process the professional autonomy is affected and the traditional hierarchy and defined roles become diffused. |
Organisational integration refers to the extent that services are delivered in a linked-up way. It is necessary to deliver population-based care because of the collective responsibility for the health and wellbeing of a population. Population-based care can be achieved through hierarchical governance structures, network-like governance mechanisms or through marked based governance structures between organisations. In the field of primary care, organisational integration is often realised in a network construction. These complex network arrangements require effective mechanisms of governance and accountability. |
System integration refers to integration of a health system to realise a holistic approach. It requires a tailor-made combination of structures and processes to fit the needs of people across the continuum of care. Both horizontal and vertical integration are needed to counteract the fragmentation and should be incorporated to provide coordinated care across the entire care continuum. |
Functional integration supports clinical, professional, organisational and system integration and includes coordination of key support functions as human resources, strategic planning, information management, financial management and quality improvement. Functional integration is the linking of information, management and financial systems around the primary process of service delivery. |
Normative integration also achieves connectivity. It can provide a common frame of reference, necessary for providing a continuum of care when various actors are in involved [3]. |
Development of the birth centre integration questionnaire
Level | Dimension | Description dimension | Determinant | Description determinant |
---|---|---|---|---|
Micro | Clinical integration | The coordination of person-focused care in a single process across time, place and discipline. | Case management | Coordination of care for clients’ with a high-risk profile (e.g. identifying risks, developing policies and guidance). |
Continuity | The organization of care is aimed to provide fluid care delivery for an individual client. | |||
Individual multidisciplinary care plan | Implementation of a multidisciplinary care plan at the individual client level. | |||
Client participation | Clients are (pro) actively involved in the design, organization and provision of care at the operational level. | |||
Meso | Professional integration | Inter-professional partnerships based on shared competences, roles, responsibilities and accountability to deliver a comprehensive continuum of care to a defined population. | Inter-professional education | Inter-professional education for professionals focused on interdisciplinary collaboration. |
Shared vision between professionals | A shared vision between professionals focused on the content of care. | |||
Multidisciplinary guidelines and protocols | Multidisciplinary guidelines and protocols are implemented in coherence at the operational level. | |||
Inter-professional governance | Inter-professional governance focused on openness, integrity and accountability between professionals at the operational level (e.g. joint accountability, appeal on pursued policies and responsibilities). | |||
Meso | Organizational integration | Inter-organizational relationships (e.g. contracting, strategic alliances, knowledge networks, mergers), including common governance mechanisms, to deliver omprehensive services to a defined population. | Interest management | A climate that attempts to bridge the various interests (e.g. social, organizational and personal interests) at the operational, tactical and strategic level. |
Performance management | Collective elaborated performance management between organizations within the collaboration. | |||
Learning organisations | Collective learning power between the organizations within the collaboration (e.g. joint research and development programs). | |||
Complaints procedure | ||||
Macro | System integration | A horizontal and vertical integrated system, based on a coherent set of (informal and formal) rules and policies between care providers and external stakeholders for the benefit of people and populations. | Available resources | Available resources in the environment of the collaboration (e.g. usable buildings, (over) capacity, professionals and funding streams). |
Stakeholder management | Engagement of various stakeholders (e.g. municipality, patient organizations and health insurance company). | |||
Good governance | Creating trust towards external stakeholders (e.g. municipality and health insurance company) due to working method, reputation, management, control and/or supervision. | |||
Environmental climate | Political, economic and social climate in the environment of the collaboration (e.g. market characteristics, regulatory framework, competition). | |||
Micro, meso, macro | Functional integration | Key support functions and activities (i.e. financial, management and information systems) structured around the primary process of service delivery, to coordinate and support accountability and decision making between organizations and professionals to add overall value to the system. | Information management | Aligned information management systems accessible at operational, tactical and strategic level (e.g. monitoring and benchmarking systems). |
Resource management | Coherent use of resources (e.g. collective real estate and funding). | |||
Service management | Aligned service management for the client (e.g. collective telephone number, counter assistance and 24-h access) | |||
Regular feedback of performance indicators | Regular feedback of performance indicators for professionals at the operational level to enable them to improve their performance. | |||
Micro, meso, macro | Normative integration | The development and maintenance of a common frame of reference (i.e. shared mission, vision, values and culture) between organizations, professional groups and individuals. | Reliable behaviour | The extent to which the agreements and promises within the collaboration are fulfilled at operational, tactical and strategic levels. |
Visionary leadership | Leadership based on a personal vision that inspires and mobilizes people. | |||
Quality features of the informal collaboration | Effectiveness and efficiency of the informal collaboration at the operational, tactical and strategic levels (e.g. group dynamics and attention to the undercurrent). | |||
Trust | The extent to which those involved in the collaboration at operational, tactical and strategic levels trusts each other. |
Data collection procedure
Data analysis
Calculating integration scores per birth centre
Cluster analysis
Results
Integration scores per birth centre
Birth Centre | Clinical Integration | Professional Integration | Organizational Integration | Functional Integration | System Integration | Normative Integration | Total Integration |
---|---|---|---|---|---|---|---|
Mean scores | |||||||
1 | 2.92 | 2.75 | 2.58 | 2.17 | 2.33 | 3.58 | 2.72 |
2 | 2.13 | 1.63 | 1.50 | 1.88 | 2.00 | 3.13 | 2.04 |
3 | 2.20 | 1.85 | 1.85 | 1.45 | 2.48 | 3.15 | 2.16 |
4 | 2.08 | 2.50 | 2.67 | 1.42 | 2.07 | 3.50 | 2.37 |
5 | 2.50 | 2.00 | 2.19 | 1.88 | 2.50 | 3.50 | 2.43 |
6 | 2.42 | 1.67 | 1.88 | 1.63 | 2.17 | 2.71 | 2.08 |
7 | 2.88 | 2.33 | 1.94 | 2.13 | 2.50 | 2.88 | 2.44 |
8 | 2.44 | 3.38 | 3.38 | 2.33 | 2.73 | 3.19 | 2.91 |
9 | 3.25 | 3.69 | 3.50 | 3.31 | 3.15 | 3.63 | 3.42 |
10 | 2.06 | 2.19 | 2.38 | 1.38 | 2.20 | 3.13 | 2.22 |
11 | 2.17 | 2.17 | 2.71 | 2.00 | 3.20 | 3.71 | 2.66 |
12 | 2.38 | 1.81 | 2.63 | 1.38 | 2.17 | 3.00 | 2.23 |
13 | 2.75 | 2.17 | 2.58 | 1.96 | 2.60 | 3.33 | 2.57 |
14 | 2.42 | 2.08 | 1.75 | 1.58 | 1.80 | 3.63 | 2.21 |
15 | 2.17 | 2.25 | 2.25 | 1.67 | 2.00 | 2.67 | 2.17 |
16 | 3.25 | 2.58 | 2.42 | 2.67 | 2.27 | 3.42 | 2.77 |
17 | 2.25 | 2.75 | 2.50 | 1.67 | 2.20 | 3.33 | 2.45 |
18 | 2.00 | 1.38 | 2.00 | 1.44 | 2.65 | 2.92 | 2.06 |
19 | 3.08 | 3.61 | 3.31 | 3.35 | 2.65 | 3.21 | 3.20 |
20 | 2.92 | 2.38 | 2.48 | 2.44 | 2.50 | 3.38 | 2.68 |
21 | 2.00 | 3.00 | 2.75 | 2.50 | 3.00 | 3.50 | 2.79 |
22 | 2.75 | 2.69 | 2.56 | 2.25 | 2.05 | 2.94 | 2.54 |
23 | 2.35 | 3.54 | 3.25 | 3.17 | 3.43 | 3.75 | 3.25 |
Cluster analysis
n (%) | Total birth centres | Profile A Mono-disciplinary-orientated birth centres (MOBC) | Profile B Mixed-cluster of birth centres (MIBC) | Profile C Multi-disciplinary-orientated birth centres (MUBC) | Subgroup differences F Test | ||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
23 (100) | 10 (43.5) | 7 (30.4) | 6 (26.1) | * p < 0.05 | |||||||||||||||
** p < 0.01 | |||||||||||||||||||
*** p < 0.001 | |||||||||||||||||||
Dimension | Determinant | Range | M | SD | Min | Max | M | SD | Min | Max | M | SD | Min | Max | M | SD | Min | Max | |
Clinical integration (CI) | Case management | 1–4 | 3.08 | 0.32 | 2.40 | 4.00 | 3.04 | 0.27 | 2.40 | 3.33 | 3.11 | 0.40 | 2.75 | 4.00 | 3.13 | 0.33 | 2.80 | 3.75 | F(2.20) = 0.17 |
Continuity | 1–4 | 2.30 | 0.49 | 2.00 | 3.50 | 2.00 | 0.00 | 2.00 | 2.00 | 2.52 | 0.39 | 2.00 | 3.00 | 2.56 | 0.74 | 2.00 | 3.50 | F(2.20) = 4.49* | |
Individual multidisciplinary care plan | 1–4 | 2.86 | 0.82 | 2.00 | 4.00 | 2.22 | 0.25 | 2.00 | 2.67 | 3.79 | 0.22 | 3.50 | 4.00 | 2.83 | 0.86 | 2.00 | 4.00 | F(2.20) = 21.91*** | |
Client participation | 1–4 | 1.77 | 0.44 | 1.00 | 2.67 | 1.58 | 0.35 | 1.00 | 2.00 | 1.99 | 0.50 | 1.00 | 2.67 | 1.83 | 0.42 | 1.33 | 2.50 | F(2.20) = 2.10 | |
Total CI | 1–4 | 2.49 | 0.40 | 2.00 | 3.25 | 2.21 | 0.15 | 2.00 | 2.42 | 2.85 | 0.23 | 2.50 | 3.25 | 2.55 | 0.50 | 2.00 | 3.25 | F(2.20) = 9.64** | |
Professional integration (PI) | Inter-professional education | 1–4 | 2.05 | 0.88 | 1.00 | 3.75 | 1.78 | 0.79 | 1.00 | 3.67 | 1.80 | 0.55 | 1.00 | 2.67 | 2.81 | 0.98 | 1.00 | 3.75 | F(2.20) = 3.77* |
Shared vision between professionals | 1–4 | 2.59 | 1.03 | 1.00 | 4.00 | 1.87 | 0.72 | 1.00 | 3.33 | 2.73 | 0.98 | 1.67 | 4.00 | 3.65 | 0.32 | 3.25 | 4.00 | F(2.20) = 11.06** | |
Multidisciplinary guidelines and protocols | 1–4 | 2.76 | 0.73 | 1.50 | 4.00 | 2.41 | 0.63 | 1.50 | 3.33 | 2.68 | 0.55 | 1.50 | 3.00 | 3.46 | 0.64 | 2.33 | 4.00 | F(2.20) = 5.70* | |
Inter-professional governance | 1–4 | 2.46 | 0.75 | 1.00 | 4.00 | 1.99 | 0.49 | 1.00 | 2.67 | 2.45 | 0.34 | 2.00 | 3.00 | 3.25 | 0.82 | 2.00 | 4.00 | F(2.20) = 9.50** | |
Total PI | 1–4 | 2.45 | 0.65 | 1.38 | 3.69 | 2.01 | 0.42 | 1.38 | 2.75 | 2.41 | 0.28 | 2.00 | 2.75 | 3.23 | 0.58 | 2.17 | 3.69 | F(2.20) = 15.01*** | |
Organizational integration (OI) | Interest management | 1–4 | 2.85 | 0.42 | 2.00 | 3.67 | 2.65 | 0.48 | 2.00 | 3.67 | 2.81 | 0.24 | 2.50 | 3.00 | 3.24 | 0.16 | 3.00 | 3.50 | F(2.20) = 5.16* |
Performance management | 1–4 | 2.65 | 1.01 | 1.00 | 4.00 | 1.97 | 0.81 | 1.00 | 3.33 | 2.65 | 0.78 | 1.67 | 3.67 | 3.79 | 0.33 | 3.33 | 4.00 | F(2.20) = 12.26*** | |
Learning organisations | 1–4 | 2.86 | 0.71 | 1.80 | 4.00 | 2.53 | 0.57 | 1.80 | 3.33 | 2.69 | 0.51 | 2.00 | 3.33 | 3.60 | 0.65 | 2.33 | 4.00 | F(2.20) = 6.89** | |
Complaints procedure | 1–4 | 1.65 | 0.61 | 1.00 | 3.25 | 1.41 | 0.44 | 1.00 | 2.25 | 1.42 | 0.47 | 1.00 | 2.25 | 2.31 | 0.57 | 1.67 | 3.25 | F(2.20) = 7.50** | |
Total OI | 1–4 | 2.48 | 0.53 | 1.50 | 3.50 | 2.14 | 0.40 | 1.50 | 2.67 | 2.39 | 0.24 | 1.94 | 2.58 | 3.15 | 0.34 | 2.71 | 3.50 | F(2.20) = 16.46*** | |
System integration (SI) | Available resources | 1–4 | 2.72 | 0.61 | 1.17 | 4.00 | 2.32 | 0.47 | 1.17 | 2.83 | 2.70 | 0.35 | 2.25 | 3.33 | 3.40 | 0.45 | 2.75 | 4.00 | F(2.20) = 11.84*** |
Stakeholder management | 1–4 | 2.20 | 0.81 | 1.00 | 4.00 | 1.66 | 0.47 | 1.00 | 2.25 | 2.10 | 0.58 | 1.33 | 3.00 | 3.22 | 0.49 | 2.67 | 4.00 | F(2.20) = 17.89*** | |
Good governance | 1–4 | 2.71 | 0.55 | 2.00 | 4.00 | 2.38 | 0.25 | 2.00 | 2.67 | 2.67 | 0.40 | 2.00 | 3.00 | 3.31 | 0.60 | 2.50 | 4.00 | F(2.20) = 9.67** | |
Environmental climate | 1–4 | 2.03 | 0.77 | 1.00 | 3.25 | 2.18 | 0.73 | 1.00 | 3.20 | 1.80 | 0.76 | 1.00 | 3.00 | 2.06 | 0.91 | 1.00 | 3.25 | F(2.20) = 0.48 | |
Total SI | 1–4 | 2.07 | 0.61 | 1.38 | 3.35 | 1.55 | 0.16 | 1.38 | 1.88 | 2.21 | 0.27 | 1.88 | 2.67 | 2.78 | 0.57 | 2.00 | 3.35 | F(2.20) = 25.19*** | |
Functional integration (FI) | Information management | 1–4 | 1.74 | 0.51 | 1.00 | 3.00 | 1.43 | 0.23 | 1.00 | 1.67 | 1.86 | 0.48 | 1.33 | 2.67 | 2.11 | 0.62 | 1.50 | 3.00 | F(2.20) = 5.07* |
Resource management | 1–4 | 2.31 | 1.07 | 1.00 | 4.00 | 1.65 | 0.60 | 1.00 | 2.50 | 2.68 | 1.03 | 1.00 | 4.00 | 3.00 | 1.22 | 1.00 | 4.00 | F(2.20) = 4.84* | |
Service management | 1–4 | 2.39 | 0.75 | 1.00 | 3.75 | 1.77 | 0.44 | 1.00 | 2.50 | 2.57 | 0.53 | 2.00 | 3.00 | 3.22 | 0.37 | 2.75 | 3.75 | F(2.20) = 20.06*** | |
Regular feedback of performance indicators | 1–4 | 1.77 | 0.86 | 1.00 | 4.00 | 1.35 | 0.58 | 1.00 | 2.50 | 1.74 | 0.56 | 1.00 | 2.50 | 2.53 | 1.10 | 1.00 | 4.00 | F(2.20) = 4.72* | |
Total FI | 1–4 | 2.46 | 0.43 | 1.80 | 3.43 | 2.17 | 0.24 | 1.80 | 2.65 | 2.39 | 0.19 | 2.05 | 2.60 | 3.03 | 0.30 | 2.65 | 3.43 | F(2.20) = 23.49*** | |
Normative integration (NI) | Reliable behaviour | 1–4 | 3.52 | 0.40 | 3.00 | 4.00 | 3.55 | 0.42 | 3.00 | 4.00 | 3.43 | 0.46 | 3.00 | 4.00 | 3.60 | 0.33 | 3.25 | 4.00 | F(2.20) = 0.30 |
Visionary leadership | 1–4 | 3.27 | 0.55 | 2.00 | 4.00 | 3.01 | 0.59 | 2.00 | 3.67 | 3.35 | 0.53 | 2.50 | 4.00 | 3.63 | 0.21 | 3.50 | 4.00 | F(2.20) = 2.95 | |
Quality features of the informal collaboration | 1–4 | 2.80 | 0.56 | 1.67 | 3.50 | 2.65 | 0.71 | 1.67 | 3.50 | 2.82 | 0.47 | 2.00 | 3.33 | 3.01 | 0.33 | 2.50 | 3.33 | F(2.20) = 0.79 | |
Trust | 1–4 | 3.48 | 0.39 | 2.67 | 4.00 | 3.26 | 0.34 | 2.67 | 3.67 | 3.56 | 0.37 | 3.00 | 4.00 | 3.75 | 0.32 | 3.25 | 4.00 | F(2.20) = 4.06* | |
Total NI | 1–4 | 3.27 | 0.31 | 2.67 | 3.75 | 3.12 | 0.31 | 2.67 | 3.63 | 3.29 | 0.27 | 2.88 | 3.58 | 3.50 | 0.25 | 3.19 | 3.75 | F(2.20) = 3.37 | |
Total Integration | Total | 1–4 | 2.54 | 0.39 | 2.04 | 3.42 | 2.20 | 0.13 | 2.04 | 2.45 | 2.59 | 0.13 | 2.43 | 2.77 | 3.04 | 0.30 | 2.66 | 3.42 | F(2.20) = 38.0 *** |