Advanced Topics
Reading 1.1 – Barriers to the Integration of Care in Inter-Organizational Settings: A Literature
Review
More often than not, the integration of care faces barriers caused by contextual,
institutional and professional factors in different domains of integrated care. Inter-
organizational collaboration is important in this regard, as many patients require a mix of
services delivered by multiple, often formally and legally independent providers.
Inter-organizational collaboration might benefit:
• The mutual exchange and transfer of information and knowledge
• Enhanced trust between providers, and the creation of synergy effects
• Reduce fragmentation
• Generate innovation in healthcare delivery
The implementation of collaboration proves to be a managerial challenge:
→ Lack of common goals or leadership
→ Regulative constraints
The study offers the following contributions:
1) It deepens our understanding on barriers to the integration of care in inter-
organizational settings by providing a systematic overview on several kinds of
barriers that can occur, on their contextual embedding, as well as underlying
mechanisms that lead to their existence.
2) This systematic literature review can guide further empirical research on the
occurrence of barriers and their causes.
3) It can help practitioners engaged in the planning or implementation of inter-
organizational, integrative health care services to avoid or overcome such barriers by
promoting awareness and enabling more reflective action.
Integration (in healthcare) = a coherent set of methods and models on the funding,
administrative, organizational, service delivery and clinical domains designed to create
connectivity, alignment and collaboration within and between the cure and care sectors.
Inter-organizational collaboration in health service delivery
Inter-organizational collaborations – as opposed to market or hierarchical relationships –
feature certain characteristics:
1) Partners within the inter-organizational relationship follow either a common goal or
purpose.
2) The organizations involved stay formally independent and autonomous, but are
obligated to their partners.
3) The relationships allow for and result from exchange, e.g. of information, resources,
activities and capabilities, and include social interaction.
4) The partners follow certain rules, norms, and structures within the relationship –
rendering the relationship either formal or informal.
5) The participants of inter-organizational relationships can also be competitors, being
for-profit, and/or public, non-profit organizations.
→ “Collaborative quality”
,Macro → Micro
• Administration
• Funding
• Organization
• Service delivery
• Clinical practice
Administration
- Regulations on a very macro/environmental level of analysis
- Governmental regulations
- Administrative functions
Funding
- Dependent on the aforementioned administrative domain
- Affects the integration of care
- Providing reimbursement for coordination practices (or not)
Organizational domain
- Characteristics of and practices within single organizations can play an important
role, e.g. in intra-organizational teamwork
Service delivery
- Staff training
- Inter-personal relationships between professionals
- Distribution of responsibilities and tasks
- More micro, individual level of analysis
Clinical domain
- Common professional languages
- Agreed understandings, practices and standards related to certain diseases
- Ongoing communication with patients
+ Inter-organizational domain
- Peculiarities of inter-organizational collaboration
- Reciprocity between autonomous organizations
Barriers = obstacles or difficulties of a material or an immaterial nature that individuals or
organizational actors need to overcome in order to achieve their aims.
Method: Systematic literature search, using 40 relevant articles.
The barrier ‘different professionalization’ was reported most frequently (n = 20), followed by
‘lack of leadership and coordination’ (n = 13) and ‘organizational versus collective interests’
(n = 13).
Most of the barriers mentioned (regarding the amount of the types of barriers and sum of
the reported numbers in each domain) are assigned to the domain of service delivery,
,followed by the inter-organizational domain. This could be an indicator that many reasons
for the slow progress or even failure of the delivery, followed by the inter-organizational
domain. This could be an indicator that many reasons for the slow progress or even failure of
the delivery of integrated care across organizational boundaries can be found in the last
domain. However, this interpretation may well underlie a bias, as we do not know if the
reviewed studies illustrate all existing barriers that hampered a collaboration or if
researchers maybe also intentionally or unintentionally focused on certain barriers.
National borders
National borders cause administrative or regulatory differences due to different healthcare
systems and languages, ‘differences in the meaning and use of relevant concepts between
countries and regions.’
Historical development
Historical developments and critical junctures, often on the macro level, influence the
behavior of organizational and individual actors. Collaboration between organizations
belonging to regions with a long history of the fragmentation of care, e.g. in regard to
specialization and ideology, may be difficult. Furthermore, in some cases, the surrounding
context traditionally sets no incentive to inter-organizational collaboration.
Regulations
Existing regulations can impede inter-organizational collaboration, either by forbidding it or
making the implementation process extremely complicated, costly and time-consuming for
the partners involved.
Lack of organizational resources and external funding
Sometimes organizations lack the resources needed to initiate and develop inter-
organizational collaboration.
Lack of leadership and coordination
Proper leadership is important for conducting collaborative activities. Inter-organizational
collaborations often involve various stakeholders with different aims. If coordination
between them is not conducted properly – for instance if organizational leaders start to
protect their territory against the collaboration the progress of collaboration can be affected
considerably.
Overprocessing = more planning takes place than implementation.
Missing actors
The failure to include a local hospital in a network of integrated care can cause difficulties.
Especially before the formation of an inter-organizational collaboration, one facet of this
barrier is the lack of knowledge about potential partner organizations.
Power imbalances and conflicts
Perceived or real power asymmetries can become a strong barrier to inter-organizational
collaboration and affect collaboration outcomes.
Differences regarding collaboration design and aims
, Differing expectations about the gestalt and vision of an inter-organizational collaboration
can also lead to controversies during network development, hampering further progress.
Incompatible organizational structures
Differing organizational structures and processes can impede inter-organizational
collaboration, e.g. by hindering common meetings due to different working arrangements,
e.g. divergent formal timetables and time horizons.
Organizational versus collective interests
Organizations calculate and pursue their own interests versus the collaborative interest. If
these interests are conflicting, barriers impeding the inter-organizational collaboration
emerge and conflicting agendas rise. Taking part in an inter-organizational collaboration also
implies a loss of organizational autonomy, e.g. if shared resources and joint planning require
common decision-making processes, that can become problematic if organizational and
collective interests do not overlap or even conflict.
Cultural distance between organizations
Organizations develop their own specific cultures, which can create barriers to inter-
organizational collaborations if organizations are not capable of managing these differences.
Former collaboration experiences
Former cooperation experiences – either with a present partner or with others – influence
both the willingness of organizations to collaborate and also their behavior within existing
collaborations.
Lack of technological standards
Inter-organizational collaboration that requires the use of common IT-infrastructure faces
formidable challenges with regard to lacking interoperability. The existence of different IT-
systems typically complicates data exchange.
Lack of mutual understanding
Inter-organizational collaborations do not materialize, are hampered, or fail if one partner
has little understanding of the goals, procedures and behavior of the other(s). obstacles arise
when different collaborating stakeholders such as the employer, the physicians or insurers
have no understanding of the actions of the rehabilitation team, which delays
communications and hampers information exchange.
Resistance to change
Organizational members do not see the usefulness of the collaboration or fear the loss of
their own professional existence. Managers of inter-organizational collaboration can face an
unwillingness to change processes, to share knowledge, and to add to the collaboration.
Different professionalization
Individuals with different professional backgrounds (e.g. physicians, nurses, managers) have
to work together. These differing backgrounds of healthcare employees can hamper inter-
organizational collaboration.
Reading 1.1 – Barriers to the Integration of Care in Inter-Organizational Settings: A Literature
Review
More often than not, the integration of care faces barriers caused by contextual,
institutional and professional factors in different domains of integrated care. Inter-
organizational collaboration is important in this regard, as many patients require a mix of
services delivered by multiple, often formally and legally independent providers.
Inter-organizational collaboration might benefit:
• The mutual exchange and transfer of information and knowledge
• Enhanced trust between providers, and the creation of synergy effects
• Reduce fragmentation
• Generate innovation in healthcare delivery
The implementation of collaboration proves to be a managerial challenge:
→ Lack of common goals or leadership
→ Regulative constraints
The study offers the following contributions:
1) It deepens our understanding on barriers to the integration of care in inter-
organizational settings by providing a systematic overview on several kinds of
barriers that can occur, on their contextual embedding, as well as underlying
mechanisms that lead to their existence.
2) This systematic literature review can guide further empirical research on the
occurrence of barriers and their causes.
3) It can help practitioners engaged in the planning or implementation of inter-
organizational, integrative health care services to avoid or overcome such barriers by
promoting awareness and enabling more reflective action.
Integration (in healthcare) = a coherent set of methods and models on the funding,
administrative, organizational, service delivery and clinical domains designed to create
connectivity, alignment and collaboration within and between the cure and care sectors.
Inter-organizational collaboration in health service delivery
Inter-organizational collaborations – as opposed to market or hierarchical relationships –
feature certain characteristics:
1) Partners within the inter-organizational relationship follow either a common goal or
purpose.
2) The organizations involved stay formally independent and autonomous, but are
obligated to their partners.
3) The relationships allow for and result from exchange, e.g. of information, resources,
activities and capabilities, and include social interaction.
4) The partners follow certain rules, norms, and structures within the relationship –
rendering the relationship either formal or informal.
5) The participants of inter-organizational relationships can also be competitors, being
for-profit, and/or public, non-profit organizations.
→ “Collaborative quality”
,Macro → Micro
• Administration
• Funding
• Organization
• Service delivery
• Clinical practice
Administration
- Regulations on a very macro/environmental level of analysis
- Governmental regulations
- Administrative functions
Funding
- Dependent on the aforementioned administrative domain
- Affects the integration of care
- Providing reimbursement for coordination practices (or not)
Organizational domain
- Characteristics of and practices within single organizations can play an important
role, e.g. in intra-organizational teamwork
Service delivery
- Staff training
- Inter-personal relationships between professionals
- Distribution of responsibilities and tasks
- More micro, individual level of analysis
Clinical domain
- Common professional languages
- Agreed understandings, practices and standards related to certain diseases
- Ongoing communication with patients
+ Inter-organizational domain
- Peculiarities of inter-organizational collaboration
- Reciprocity between autonomous organizations
Barriers = obstacles or difficulties of a material or an immaterial nature that individuals or
organizational actors need to overcome in order to achieve their aims.
Method: Systematic literature search, using 40 relevant articles.
The barrier ‘different professionalization’ was reported most frequently (n = 20), followed by
‘lack of leadership and coordination’ (n = 13) and ‘organizational versus collective interests’
(n = 13).
Most of the barriers mentioned (regarding the amount of the types of barriers and sum of
the reported numbers in each domain) are assigned to the domain of service delivery,
,followed by the inter-organizational domain. This could be an indicator that many reasons
for the slow progress or even failure of the delivery, followed by the inter-organizational
domain. This could be an indicator that many reasons for the slow progress or even failure of
the delivery of integrated care across organizational boundaries can be found in the last
domain. However, this interpretation may well underlie a bias, as we do not know if the
reviewed studies illustrate all existing barriers that hampered a collaboration or if
researchers maybe also intentionally or unintentionally focused on certain barriers.
National borders
National borders cause administrative or regulatory differences due to different healthcare
systems and languages, ‘differences in the meaning and use of relevant concepts between
countries and regions.’
Historical development
Historical developments and critical junctures, often on the macro level, influence the
behavior of organizational and individual actors. Collaboration between organizations
belonging to regions with a long history of the fragmentation of care, e.g. in regard to
specialization and ideology, may be difficult. Furthermore, in some cases, the surrounding
context traditionally sets no incentive to inter-organizational collaboration.
Regulations
Existing regulations can impede inter-organizational collaboration, either by forbidding it or
making the implementation process extremely complicated, costly and time-consuming for
the partners involved.
Lack of organizational resources and external funding
Sometimes organizations lack the resources needed to initiate and develop inter-
organizational collaboration.
Lack of leadership and coordination
Proper leadership is important for conducting collaborative activities. Inter-organizational
collaborations often involve various stakeholders with different aims. If coordination
between them is not conducted properly – for instance if organizational leaders start to
protect their territory against the collaboration the progress of collaboration can be affected
considerably.
Overprocessing = more planning takes place than implementation.
Missing actors
The failure to include a local hospital in a network of integrated care can cause difficulties.
Especially before the formation of an inter-organizational collaboration, one facet of this
barrier is the lack of knowledge about potential partner organizations.
Power imbalances and conflicts
Perceived or real power asymmetries can become a strong barrier to inter-organizational
collaboration and affect collaboration outcomes.
Differences regarding collaboration design and aims
, Differing expectations about the gestalt and vision of an inter-organizational collaboration
can also lead to controversies during network development, hampering further progress.
Incompatible organizational structures
Differing organizational structures and processes can impede inter-organizational
collaboration, e.g. by hindering common meetings due to different working arrangements,
e.g. divergent formal timetables and time horizons.
Organizational versus collective interests
Organizations calculate and pursue their own interests versus the collaborative interest. If
these interests are conflicting, barriers impeding the inter-organizational collaboration
emerge and conflicting agendas rise. Taking part in an inter-organizational collaboration also
implies a loss of organizational autonomy, e.g. if shared resources and joint planning require
common decision-making processes, that can become problematic if organizational and
collective interests do not overlap or even conflict.
Cultural distance between organizations
Organizations develop their own specific cultures, which can create barriers to inter-
organizational collaborations if organizations are not capable of managing these differences.
Former collaboration experiences
Former cooperation experiences – either with a present partner or with others – influence
both the willingness of organizations to collaborate and also their behavior within existing
collaborations.
Lack of technological standards
Inter-organizational collaboration that requires the use of common IT-infrastructure faces
formidable challenges with regard to lacking interoperability. The existence of different IT-
systems typically complicates data exchange.
Lack of mutual understanding
Inter-organizational collaborations do not materialize, are hampered, or fail if one partner
has little understanding of the goals, procedures and behavior of the other(s). obstacles arise
when different collaborating stakeholders such as the employer, the physicians or insurers
have no understanding of the actions of the rehabilitation team, which delays
communications and hampers information exchange.
Resistance to change
Organizational members do not see the usefulness of the collaboration or fear the loss of
their own professional existence. Managers of inter-organizational collaboration can face an
unwillingness to change processes, to share knowledge, and to add to the collaboration.
Different professionalization
Individuals with different professional backgrounds (e.g. physicians, nurses, managers) have
to work together. These differing backgrounds of healthcare employees can hamper inter-
organizational collaboration.
