Using Standards and Tools to Advance Integrated Care and Drive Coordinated System Change

Background: Integrated care is essential to achieving the Sextuple Aim, improving (1) quality and experience of patient care; (2) population health; (3) quality of work and satisfaction of healthcare providers; (4) equity and inclusion; (5) cost reduction and (6) environmental sustainability. Despite growing global commitment, many health systems continue to struggle with how to move from vision to action. Through consultation with interest holders worldwide, including patients, families, providers, and policymakers, we heard a clear message: there is a need for practical, co-designed tools to make the integrated people-centred care a reality.

In response, Health Standards Organization (HSO) developed the world’s first Integrated People-Centred Health Systems (IPCHS) Standard, framed by 10 design principles that were co-designed and demonstrated through evidence and lived experience as necessary to advance integrated care and population health. These principles reflect what is essential for whole system change in partnership with people and communities.

 

Approach: To support implementation of the IPCHS Standard and drive coordinated transformation across macro, meso, and micro levels, HSO developed three integrated care tools:

1.Maturity Assessment Tool – Helps health systems and networks reflect their level of integration across all 10 design principles using a five-level maturity framework. It informs strategic planning and system-wide alignment.

2.Organizational Assessment Tool – Focuses on five design principles within the control of service delivery organizations, helping them improve access, equity, safety, and care transitions.

3.Patient Pathway Assessment Tool – A co-designed, people-centred method for mapping care journeys, identifying opportunities for improved coordination, flow, and team-based care.

 

These tools were co-designed with patients, families, providers, operational and policy leaders to help networks and organizations understand their current state, identify strengths and risks, prioritize actions based on local context, and engage in continuous improvement through structured monitoring and shared learning.

 

 

 

Results: Early testing and implementation has demonstrated their value in enabling organizations and systems to:

• Benchmark integration efforts using a common, evidence-informed framework.
• Engage people and communities as active partners in care design and delivery.
• Translate policy into practice through actionable insights.
• Foster adaptive learning cultures and performance management systems.

 

These tools have supported meaningful dialogue across sectors and levels of governance, helping to close the gap between aspiration and reality in integrated care.

 

Implications: These three tools are designed to work together to provide a comprehensive view of integrated care across system, organizational, and patient levels. When used in combination, they offer complementary insights that help identify gaps, align efforts, and inform targeted and coordinated improvements.

 

The HSO integrated care tools offer a scalable, practical pathway for systems seeking to move from fragmented services to truly integrated, people-centred care. By aligning efforts across macro (policy), meso (organizational), and micro (pathway) levels, these tools support a unified approach to system transformation. They help interest holders continuously reflect on and answer the critical question: “Are we actually integrating?” and “Are we actually improving?” not just once, but collectively as part of an ongoing journey grounded in evidence, lived experience, partnership and improvement.