Table 1
Indicators for collaboration (based on the model and typology of D’Amour 2008).
| CORE CONSTRUCT | INDICATOR | DESCRIPTION |
|---|---|---|
| Shared goals and vision | Shared Goals | The extent to which common goals have been formed and are supported by all collaborating partners. |
| Client-centred orientation vs. other allegiances | The existence of asymmetric interests among partners and whether these are being expressed and negotiated. | |
| Internalization | Mutual acquaintanceship | The presence of social conditions through which professionals get to know each other personally and professionally and create a sense of belonging to a group. |
| Trust | Whether trust or uncertainty exists in each other’s competencies and ability to assume responsibilities, and whether this is grounded by previous experiences. | |
| Governance | Centrality | Explicit and active involvement of central authorities with a well-defined strategic and political role to foster consensus and improve collaboration. |
| Leadership | Type of leadership and balance of power in the collaboration: emergent or position-related, ad-hoc decisions or complete policy and shared or monopolistic. | |
| Support for innovation | The extent to which the organization draws on expertise needed to support complementary learning processes. | |
| Connectivity | Connection between parties through venues to discuss problems, find consensus and constructing bonds. | |
| Formalization | Formalization tools | The degree of consensual agreements about roles and responsibilities: whether these are jointly defined and respected by all parties. |
| Information exchange | The existence and appropriate use of an information infrastructure that meets care professionals’ needs for rapid, complete exchanges of information. |
Figure 1
Study design: timeline and action research cycles per learning session.
OCN, obstetric care network. PROM, patient-reported outcome measure. QI, quality improvement.
Implementation period was 12 months in each OCN.
Table 2
Characteristics of learning sessions.
| SESSION 1 | SESSION 2 | SESSION 3 | SESSION 4 | SESSION 5 | TOTAL | TOTAL UNIQUE | |
|---|---|---|---|---|---|---|---|
| Region | OCN1 | OCN2 | OCN2 | OCN3 | OCN3 | ||
| Location | online | online | live | online | online | ||
| Participants | 16 | 25 | 11 | 16 | 19 | 87 | 70 |
| community midwife | 9 | 11 | 5 | 8 | 10 | 43 | 33 |
| hospital midwife | 1 | 6 | 3 | 3 | 2 | 15 | 12 |
| obstetrician/gynaecologist | 2 | 2 | 2 | 2 | 4 | 12 | 9 |
| obstetric resident | 6 | 1 | 2 | 9 | 9 | ||
| youth care professional | 1 | 1 | 1 | ||||
| obstetric nurse | 1 | 2 | 1 | 4 | 3 | ||
| maternity care | 2 | 2 | 2 | ||||
| neonatologist/paediatrician | 1 | 1 | 1 |
[i] OCN, obstetric care network.
Figure 2
Collaboration levels of participating OCN.
These Kiviat graphs map the collaboration per OCN: a score of 1 to 3 is assigned to each of the 10 indicators depending on the level of achievement of the indicator in the OCN [30]. OCN, obstetric care network.
| Interdisciplinary discussion | Q1 Clinical midwife OCN2, focus group – “It [the subgroup discussion] is very small and compact, everyone brings their expertise from their own profession. I also think that it goes very harmonious. And as a result, such follow-up visit [improvement actions], that it arises in both groups: that wouldn’t emerge in a regular meeting.” |
| Interdisciplinary discussion and data insight | Q2 Clinical midwife OCN3, focus group – “In the past, we did look regularly at clinical data and actions were taken. [..] But then, I agree with [a gynaecologist], in a meeting like this one, where you can also discuss data more in-dept and concrete with each other [..] then I think you will be able to realize improvements and adjustments much better together.” |
| Follow up of actions | Q3 Gynaecologist OCN3, observation of preparation meeting – “GYN states they were still habituating in the first session and must seek as OCN who picks up the actions. The actions of first session have been submitted to the OCN board but have remained there.” |
| Engage all disciplines | Q4 Clinical midwife OCN2, focus group – “The intention is that we will involve nurses and the maternity caregivers much more in the OCN, and inform them much more about what it all means and what topics are at stake. And that they also have input on that.” |
Table 3
Framework analysis of network collaboration and learning along D’Amour model.
| INDICATORS OF COLLABORATION | THEMATIC ANALYSIS(SUMMARY WITH SUBTHEMES IN BOLD) |
|---|---|
| Shared goals | All OCN had a shared patient-centred goal: best possible outcomes and continuity of care. Year plans to reach their goal were formalized in OCNs to various extent, and in each organisation (e.g., a hospital) separately. This could lead to fragmentation, dependent on the network’s governance. For learning, shared goals were important, but should be concise and focused (not too many or too broad). |
| Client-centred orientation vs. other allegiances | All OCN centred patients in their vision, but it differed to what extent other allegiances overruled that (e.g., professional autonomy, financial structures). Also, professionals had divergent views on what benefits patients most. All OCN wished to involve patient views in learning/improving, especially when selecting or evaluating new initiatives, but struggled to do so (see information exchange). |
| Mutual acquaintanceship | In all OCN, professionals stated that knowing each other and meeting regularly were of greatest importance for good collaboration. When feeling part of the OCN was limited to a few key participants, the network was depended on the same people who were very motivated but needed broader engagement for results. Participants identified stakeholders needed for learning as all professionals involved in care and patients themselves. Yet in all OCN, engaging nurses and maternity care assistants in network activities was challenging. Knowing what occurs in the OCN and experiencing their valid contribution could help them become more involved. |
| Trust | Care professionals stressed trust as most important, the base, for collaboration and joint learning/improving. Important for trust were respect for divergent opinions and acknowledgement for qualities across disciplines. All OCN had built some level of trust from fragile to grounded, but differed in whether that was maintained over time, and how broadly it was shared across professionals. Trust was determinative for working pleasure/atmosphere perceived by care professionals and was mostly influenced by the level of connectivity and mutual acquaintanceship. |
| Centrality | Centrality was not often chosen or stated by care professionals as important factor, but indirectly they mentioned that improvement initiatives should not overlap, and consensus and clarity existed on goals and plans of the OCN. In OCN with an inactive central body (for several reasons, see leadership), initiatives were fragmented and proceeded slow as it was harder to allocate actions. |
| Leadership | Leadership varied across the OCNs and noticeably influenced the ability to learn and innovate together. If leadership patterns were observed more fragmented across organizations, ad-hoc decisions and unclarity where decisions should be made often resulted in top-down decisions eventually – which were then less likely to be accepted by professionals in practice. Leadership structures were still developing, and professionals noted that its changes affected their connectivity and mutual acquaintanceship. |
| Support for innovation | OCNs experienced little support not necessarily in a lack of expertise, but in time (workload, priorities) and resources (data availability and analysis, digital support). In two OCNs the working group for quality improvement was inactive or even absent. In OCN2 it was stated they ‘bought time for innovation’ to some extent by allocating administrative support and a quality manager for the OCN, possible via a joint reimbursement structure. Care professionals indicated that learning and QI felt as a normal part of their professional role. On a personal level, they learn and improve every day during work, but network level learning or QI always comes on top of their normal job, often in late hours as patient care comes first. For care professionals, learning/improving was stated to be easier within organisations than in a network (challenging to engage all stakeholders) but they expect most value for patients from a network approach. |
| Connectivity | Connectivity was highly important for collaboration and innovation, both from professional’s views as from observations. First, regular venues for discussion were essential to form consensus or accept differences in vision and make use of each other’s expertise. Second, connectivity in the way that professionals knew from each other what they were working on and what their level of commitment was. Both contributed positively to trust between OCN professionals, their sense of belonging (mutual acquaintanceship) and ability to work simultaneously instead of fragmented. |
| Formalization tools | All OCN experienced positive results from their joint formalization tools (e.g., joint protocols, shared care pathways, standard collaboration partners). In the past years, this has been their primary focus to improve quality and continuity of care. While many survey respondents expressed a need for more formalization, others emphasized that attention should remain for patient’s values and individual choices in care paths. In QI, formalization was considered and observed as a tool to embed actions in practice. |
| Information exchange | As almost all organisations worked in different EHRs, each OCN faced problems with information exchange (i.e., e-mail, fax, on paper) and mandated a shared or connected EHR to enable easier communication in practice and better access to aggregated data for learning and QI. Reliable data were stated essential for QI and learning but are hard to access or require much effort. Moreover, patient-reported data are not accessible at network level at all (except during the implementation period), making it difficult to involve patient views in learning and QI. |
[i] OCN, obstetric care network. EHR, electronic health record. AR, action research. QI, Quality Improvement.
| Collaboration baseline | Q5 Clinical midwife OCN1, focus group – “I think it’s until you have your act together as OCN that it will be fun to look at those outcome data together.” |
| Trust and other allegiances | Q6 Obstetric resident OCN2, preparation survey (item 6: when is the session successful for you?) – “If we work together on outcomes without restrictions in trust or finances/autonomy: ‘what is best for the pregnant woman?’” |
| Connectivity vs leadership | Q7 Gynaecologist OCN3, focus group – “I also think that what she said [statement of clinical midwife] is a somewhat broader endorsed dissatisfaction. That, with the implementation of the new [leadership] structure, too much goes via mandate or too much goes via a limited number of people. That the joint meetings [in the past] really added something.” |
| Information exchange | Q8 Obstetric resident OCN3, preparation survey (item 2: what do you need as professional to address these themes?) – “A joint EPD, this also ensures more efficiency and less chance of errors, because then we don’t have to retype anything.” |
| Support for innovation: joint reimbursement | Q9 Gynaecologist OCN2, focus group – “But we can buy that time by being an integrated care organization: by having a quality officer, having secretarial support, having a manager. We buy off all kinds of things, so to speak, so that we have time for learning and improving” |
Figure 3
Joint learning in relation to collaboration and innovation in care networks.
| Introduction: All attendants of the learning sessions are asked to complete these preparation questions. For you as preparation to the session and for us to organize a valuable session fitted to your OCN and patient population. |
| Baseline: For which organisation do you work? What is your function? |
| Survey: 1. In the learning session we will work on the current goals in the OCN [adapted per session and region]. Which of these themes should we address as OCN first? 2. What do you need as professional to address these themes? 3. Do you miss any issues/themes that we could improve as OCN? For example, specific patient groups, outcomes, or experiences. 4. According to you, which activities (initiatives/agreements/collaboration) in the OCN have yielded most value (client/patient; care professional; financially)? 5. What should we stop doing? 6. When is the session successful for you? |