Barriers to the integration of care in inter-organisational settings: A literature review
Health service delivery profits from integration across time, place and discipline
Integrated care in its various forms can produce benefits such as
o Quality enhencement
o Increased system efficiency and cost reduction
o Higher client satisfaction
o Batter access to care
The integration of care can be achieved by employing different forms of governance,
ranging from the integration of tasks within organisational hierarchies (e.g. inter-
professional collaboration within a single organisation such as a hospital) through
collaborative inter-organisational relations to more market-oriented forms of
coordination (where integration can be reached on a short-term, contractual basis)
Integration can help to coordinate previously separated tasks of care provision not only
across professional or sectoral, but also organisational boundaries
The integration of care faces barriers caused by contextual, institutional and professional
factors in different domains of integrated care
Inter-organisational collaboration is important in this regard, as many patients require a
mix of services delivered by multiple, often formally and legally independent providers
Inter-organisational collaboration can thus reduce fragmentation within healthcare
systems and provide the potential to generate innovation in healthcare delivery (e.g. by
bringing together complementary competences)
Understanding barriers that impede the development of collaborative inter-
organisational relationships can promote the successful implementation of integrated
care in such settings
Many inter-organisational collaborations fail and the implementation of collaboration
proves to be a managerial challenge
Further attention is called for to barriers to the integration of care in inter-organisational
settings, as there is a significant gap between what 'could' be possible in collaborative
practice and what is actually achieved within most inter-organisational relationships
Some barriers occurring during inter-organisational collaboration are particular to this
governance form due to the existence of the inter-organisational domain, where, for
instance, formally autonomous and culturally different organisations collaborate
Inter-organisational collaborations in healthcare appear in several forms, e.g. as dyadic
relationships between two partner organisations or as inter-organisational networks,
implying relationships between at least three partners
They can take on - following the integration needs of care – several directions: vertical
collaboration along the chain of health service delivery, including, for instance,
collaboration between providers of primary and secondary care, or horizontal
collaboration between organisations of the same kind, e.g. between general
practitioners.
Inter-organisational collaboration differs from intra-organisational collaboration that
takes place within one organisation, e.g. between different professions, team members
or across teams.
Inter-organisational collaborations - as opposed to market or hierarchical relationships -
feature certain characteristics:
o Partners within the inter-organisational relationship follow either a common
goal or purpose
o The organisations involved stay formally independent and autonomous, but
are obligated to their partners
o The relationships allow for and result from exchange, e.g. of information,
resources, activities and capabilities, and include social interaction
, o The partners follow certain rules, norms and structures within the
relationship - rendering the relationship either formal or informal
o The participants of inter-organisational relationships can also be
competitors, being for-profit, and/or public, non profit organisations.
Not just any inter-organisational relationship between two or more organisations can be
considered an inter-organisational collaboration; it all depends on the 'collaborative
quality', which is no easy to create and maintain
There is agreement that inter-organisational collaborations differ significantly from
market and hierarchical relationships regarding their content and governance of
interaction
In contrast to the rather static definintion of inter-organisational collaboration as a
governance form between market and hierarchy, each inter-organisational collaboration
underlies a dynamic, context-dependent, and history-laden process.
Five domains, representing certain fields of social action that are relevant for the
integration of care, thereby also applying to the integration of care in inter-
organisational settings. They describe these domains as ranging from the macro to the
micro level of analysis: the domains of
o Administration: The most extensive domain affecting the integration of care,
Including regulations, on a very macro or environmental level of analysis
Natural borders: causing administrative or regulatory
differences due to different healthcare systems and languages
Historical developments: historical developments and critical
junctures, often on the macro level, influence the behaviour of
organisational and individual actors
Regulations: existing regulations can impede inter-
organisational collaboration, either by forbidding it or by making
the implementation process extremely complicated, costly and
time-consuming for the partners involved.
o Funding: Often dependent on the aforementioned administrative domain,
heavily affecting the integration of care, e.g. by either providing
reimbursement for coordination of practices or not
Lack of organisational resources and external funding
o Organisation: Within this domain, characteristics of and practices within
single organisations can play an important role, e.g. in intra-organisational
teamwork
Organisational vs. Collective interests: organisations calculate
and pursue their own interests versus the collaborative interest.
If these interests are conflicting, barriers impeding the inter-
organisational collaboration emerge and conflicting agendas
arise.
Cultural distance between organisations: organisations develop
their own specific cultures, which can create barriers to inter-
organisational collaborations if organisations are not capable of
managing these differences. Different orientations and norms
result from various underlying cultural and institutional logics
(e.g. regarding the meaning of time and ways of working)
Former collaboration experiences: former cooperation
experiences - either with a present partner or with others -
influence both the willingness of organisations to collaborate
and also their behaviour within existing collaborations
Health service delivery profits from integration across time, place and discipline
Integrated care in its various forms can produce benefits such as
o Quality enhencement
o Increased system efficiency and cost reduction
o Higher client satisfaction
o Batter access to care
The integration of care can be achieved by employing different forms of governance,
ranging from the integration of tasks within organisational hierarchies (e.g. inter-
professional collaboration within a single organisation such as a hospital) through
collaborative inter-organisational relations to more market-oriented forms of
coordination (where integration can be reached on a short-term, contractual basis)
Integration can help to coordinate previously separated tasks of care provision not only
across professional or sectoral, but also organisational boundaries
The integration of care faces barriers caused by contextual, institutional and professional
factors in different domains of integrated care
Inter-organisational collaboration is important in this regard, as many patients require a
mix of services delivered by multiple, often formally and legally independent providers
Inter-organisational collaboration can thus reduce fragmentation within healthcare
systems and provide the potential to generate innovation in healthcare delivery (e.g. by
bringing together complementary competences)
Understanding barriers that impede the development of collaborative inter-
organisational relationships can promote the successful implementation of integrated
care in such settings
Many inter-organisational collaborations fail and the implementation of collaboration
proves to be a managerial challenge
Further attention is called for to barriers to the integration of care in inter-organisational
settings, as there is a significant gap between what 'could' be possible in collaborative
practice and what is actually achieved within most inter-organisational relationships
Some barriers occurring during inter-organisational collaboration are particular to this
governance form due to the existence of the inter-organisational domain, where, for
instance, formally autonomous and culturally different organisations collaborate
Inter-organisational collaborations in healthcare appear in several forms, e.g. as dyadic
relationships between two partner organisations or as inter-organisational networks,
implying relationships between at least three partners
They can take on - following the integration needs of care – several directions: vertical
collaboration along the chain of health service delivery, including, for instance,
collaboration between providers of primary and secondary care, or horizontal
collaboration between organisations of the same kind, e.g. between general
practitioners.
Inter-organisational collaboration differs from intra-organisational collaboration that
takes place within one organisation, e.g. between different professions, team members
or across teams.
Inter-organisational collaborations - as opposed to market or hierarchical relationships -
feature certain characteristics:
o Partners within the inter-organisational relationship follow either a common
goal or purpose
o The organisations involved stay formally independent and autonomous, but
are obligated to their partners
o The relationships allow for and result from exchange, e.g. of information,
resources, activities and capabilities, and include social interaction
, o The partners follow certain rules, norms and structures within the
relationship - rendering the relationship either formal or informal
o The participants of inter-organisational relationships can also be
competitors, being for-profit, and/or public, non profit organisations.
Not just any inter-organisational relationship between two or more organisations can be
considered an inter-organisational collaboration; it all depends on the 'collaborative
quality', which is no easy to create and maintain
There is agreement that inter-organisational collaborations differ significantly from
market and hierarchical relationships regarding their content and governance of
interaction
In contrast to the rather static definintion of inter-organisational collaboration as a
governance form between market and hierarchy, each inter-organisational collaboration
underlies a dynamic, context-dependent, and history-laden process.
Five domains, representing certain fields of social action that are relevant for the
integration of care, thereby also applying to the integration of care in inter-
organisational settings. They describe these domains as ranging from the macro to the
micro level of analysis: the domains of
o Administration: The most extensive domain affecting the integration of care,
Including regulations, on a very macro or environmental level of analysis
Natural borders: causing administrative or regulatory
differences due to different healthcare systems and languages
Historical developments: historical developments and critical
junctures, often on the macro level, influence the behaviour of
organisational and individual actors
Regulations: existing regulations can impede inter-
organisational collaboration, either by forbidding it or by making
the implementation process extremely complicated, costly and
time-consuming for the partners involved.
o Funding: Often dependent on the aforementioned administrative domain,
heavily affecting the integration of care, e.g. by either providing
reimbursement for coordination of practices or not
Lack of organisational resources and external funding
o Organisation: Within this domain, characteristics of and practices within
single organisations can play an important role, e.g. in intra-organisational
teamwork
Organisational vs. Collective interests: organisations calculate
and pursue their own interests versus the collaborative interest.
If these interests are conflicting, barriers impeding the inter-
organisational collaboration emerge and conflicting agendas
arise.
Cultural distance between organisations: organisations develop
their own specific cultures, which can create barriers to inter-
organisational collaborations if organisations are not capable of
managing these differences. Different orientations and norms
result from various underlying cultural and institutional logics
(e.g. regarding the meaning of time and ways of working)
Former collaboration experiences: former cooperation
experiences - either with a present partner or with others -
influence both the willingness of organisations to collaborate
and also their behaviour within existing collaborations
