Collaboration process for integrated social and health care strategy implementation

Introduction

The South Karelia District of Social and Health Services (Eksote) executes a challenging and complex health care integration process. The goal of the newly established organisation is to ensure equal access to social and health care services to all citizens in the region, across the boundaries of municipalities. The effectiveness of service delivery has been enhanced due to better co-operation of different social and health care organisations.

The integration of care is a fundamental challenge in the field of social and health care. Developing strategies and operating models that enable the functioning of client-oriented integrated social and health care within an integrated organisational structure, as well as ensuring effective change management, require tools. Eksote is a huge, exceptional structural solution where many different organisations have been merged into one organisation. To get this type of a new organisation functioning successfully to achieve its objectives, strong and effective change management and appropriate methods to execute it are required.

This paper presents a case study of implementing an integrated health care strategy at Eksote. The paper introduces a multi-phase collaboration process for developing commonly agreed tasks to implement the strategy in the new organisation. These tasks can be described as a strategic roadmap for the organisation. Three of the authors of this study have been closely involved in the development of the Eksote integration (the development director of Eksote, the project manager and the integration consultant), and two of the authors are university researchers specialized in collaboration processes and technologies.

Integrated social and health care services at Eksote

The provision of integrated health and social care has been advocated by policy-makers in Europe [1–2]. Integrated care is a frequently used concept, which has so far not been unambiguously defined [3]. At the moment various kinds of definitions are used [4]. The different definitions have emphasised the perspectives of the client, service structure, or the financier, mainly the society. For example in the Procare project the term ‘integrated care’ stood for care services which were coordinated by one unit aiming to ensure cost effectiveness, better quality and increased client satisfaction [5].

The purpose of integrated care is to provide care without a service gap, fragmentation or lack of cooperation [6]. The main objectives from the perspective of the society are cost effectiveness and enhancing productivity [5, 7]. Other objectives include furthering the use of services that are based on the needs of clients, and decreasing the use of expensive hospital services [8].

Alaszewski et al. [9] identify structural integration as one approach to integrated care. Structural integration is mainly a matter of organisational structure (e.g. bringing together the staff and resources in a single organisation under a unified hierarchical structure). Their study suggests that structural integration may improve the quality of homecare, as it creates favourable conditions for deeper integration and removes obstacles hindering interdisciplinary collaboration. However, in order to be successful, strong change management is essential [10].

In South Karelia, a region situated in South-Eastern Finland, the previously separate municipal health care and social services (see Figure 1, stage 1) were integrated into a new organisation called Eksote in the beginning of 2010 (Figure 1, stage 2). Since then Eksote has arranged secondary health care, primary health care, care for the elderly, and social welfare services for its eight member municipalities. Eksote works for delivering patient-oriented care to the approximately 130,000 citizens of South Karelia. It employs approximately 4100 people and has a budget of 370 million euros. Eksote operates in a geographical area of over 5600 square kilometres. The main reasons for the large organisational change, where Eksote was established, were solving claimed problems in economy, efficiency and service quality (e.g. equal access, continuity, client-orientation, and need-based service).

There is a dual structure in health care in Finland: one for primary care with municipality-based units and the other for secondary care with region-based units. Two types of organisations have provided primary care after the recent extensive mergers started in the 1990s, where municipal primary care and social service organisations were merged (e.g. [10]). These two types of organisations for primary care are (1) primary health care centres and (2) joint health and social centres. An exceptional feature of the Finnish primary care system has always been an extensive array of services, which grew enormously when all social services were included under the same administrative roof with primary care. Finnish municipalities are responsible for organising primary health care.

The other tier of the Finnish health care system is region-based secondary health care (SHC), which was provided by 21 specialised care districts maintained by 360 municipalities until 2009, when one of these 21 districts (South Karelia) was combined to Eksote. Since then the remaining 20 specialised care districts have continued to provide only secondary health care. The strict primary-secondary care divide existed in the whole of Finland until the establishment of Eksote.

Both systems (primary and secondary health) have extensive public sector administration with local politicians as decision-makers at the top with hierarchical management structures under them. Eksote is a public sector organisation.

The integrated organisation creates excellent possibilities for developing social and health care services for a larger area as a single entity. Eksote plans to develop the integrated service structure further into the next stage (Figure 1, stage 3), where the connections and ties between different actors within the organisation are clear and functional. Additionally, Eksote hopes to create a partnership network and to strengthen flexible and client-oriented cooperation with different actors, such as the Social Insurance Institution of Finland (Kela), the Employment and Economic Development Office (Mol), the third sector, the private sector, and other municipal actors. Integrated service processes are more functional, cost effective and client-oriented.

The goal of Eksote is to increase the productivity of work by developing the processes without decreasing the quality of care. Eksote aims to define a new process model based on “a clean slate”, so that the old municipal or organisational borders will not affect the planning process. The development team¹ at Eksote is currently working to create new client-oriented and cost-effective service processes that span over different professional areas.

The traditional way of thinking, stemming from units and municipalities, has to be replaced with comprehensive client and process-oriented thinking in order to ensure that the strategy of Eksote will succeed. The new organisation has to create commonly agreed operating models which can steer all actors towards the common goal. In the former, traditional model, all social and health care actors functioned in different organisations, and furthermore, the services were arranged by eight different municipalities separately (Figure 1, stage 1). Secondary health care (SHC) was a region-based multipurpose organisation responsible for health and social services for the whole area before Eksote was formed. Thus, before the merger to Eksote, SHC was of a very different form, including the organisations of health, social service, and joint health and social service units.

Figuratively speaking, Eksote turns territories into resources. One of the most essential functional objectives is to reduce the use of institutional care radically. The whole care process of the client has to be seen as one continuum which begins from home and continues fluently back home again. This requires seamless cooperation in the network of actors. Implementing the strategy requires turning the strategic goals into distinct practical actions. Finding sufficient time for working on the strategic goals and new common operating models was found challenging in the new organisation. Those in charge were well aware of the development needs of the process in their own specialty areas. The development needs were often connected to the interfaces between the previously separated organisational units. A method enabling the collecting of executive and middle management level managers’ insights and allowing working on ideas was called for.

GDSS technology to support collaboration

In complex planning and decision-making situations which influence many organisational units and other actors, it is important to create consensus and commitment to the decisions among the people who are needed in successful implementation of the plans. Even if the decision or plan seems good on paper, the implementation process could be a total failure if the people in the organisation are not satisfied and willing to execute it in practice. The commitment and approval of the people are in a very important role in successful implementation of the decisions. If the people can participate enough in the planning process, the reasons affecting the final plan become clearer to them. When the people understand the background of the problem better, they can plan the possible actions and understand the whole situation better. When their understanding is on a higher level, they can approve of the decisions and are committed to them [11].

A group decision support system (GDSS) is a collection of software applications aimed at facilitating group work, allowing collaboration either on-site or out of different places. A typical face-to-face GDSS facility comprises a variable number of terminals in a network, combined with various audiovisual systems. The concept aims at bringing systematic procedures and benefits from IT development to support group work in a manageable way. This is done by enhancing the process gains and reducing the process losses occurring in a teamwork environment.

Collaboration technologies support the group work process and improve the productivity of meetings, either by speeding up the meeting process or by improving the quality of the results. The GDSS is superior to a conventional meeting. It offers several possibilities for supporting a group in promoting cooperation and effectiveness (see Table 1).

The decision room at Lappeenranta University of Technology was utilized in the Eksote case. The room is a PC-equipped Local Area Network-based meeting room designed especially for decision-making, and various commonly used decision support software have been installed. The main group support software of the studio is the GroupSystems (www.groupsystems.com). The GroupSystems comprises half a dozen different tightly integrated applications (e.g. Categorizer and Vote), which support different phases of group processes, such as brainstorming, list building, information gathering, voting, organising, prioritising, and consensus building. Figure 2 illustrates the layout of the facility.

The laboratory has been designed to look like an ordinary meeting room, but the horseshoe-shaped conference table houses ten workstations hidden inside the table, which allows quick and flexible switching between computer-supported and ordinary meeting activities. In addition, the displays are under the glass surface of the table so that the displays do not dominate the appearance of the room, and every participant has a direct eye contact with the others.

Framework for applying GDSS at Eksote

The main target of the GDSS-supported collaboration process was to create a detailed roadmap to successful integration strategy implementation. The collaboration process was carried out in a period of two months. The collaboration process was divided into four main phases, two of them supported by GDSS meetings, as shown in Figure 3.

An expert panel of 13 participants was used in the collaboration process. The participants represented different functions in the Eksote organisation, and most of them belonged to the management team. The participants were directors and managers, for example the development director, CEO, health care service manager, elderly-care service manager, family and social care service manager, chief administrative physician, mental health service manager, and director of homecare for the elderly.

The advantages and challenges of the GDSS framework

Meeting satisfaction is an important measure of collaboration technology effectiveness, because unless the use of technology produces an increase in meeting satisfaction, it is unlikely that the users will seek to adopt the technology. In the Eksote case the participants experienced the designed collaboration process generally as effective and useful. According to the comments and the authors’ experiences, the participants saw the focused discussion on the important ideas and particularly on the major opinion differences very useful. The use of the GDSS process was seen to lead to goal-oriented, efficient group work, in which the focus was strictly on the issues at hand. The developed process was seen as time-efficient, bringing apparently significant time savings in the group work.

On the basis of the case experiences, it seems that the GDSS process can facilitate collaboration with different units and make the meetings more effective and fruitful. The process seems to help obtain in-depth understanding of development needs and requirements in a large organisational change. The case experiences also indicated that features that are likely to improve the development process are the ability to collect a large amount of detailed information and to analyse and evaluate the collected information with the formed development team with participants from different units.

It seems that the quality and usability of the results depend on the groups’ expertise on the subject. The meeting process supports group work but it does not replace the need of expertise and knowledge of the participants. Therefore it was very important to select people who knew about the challenges at Eksote and who had the needed authority for the implementation of decisions in the organisation.

The participants gave very positive comments about the meetings and the GDSS process. For instance, the following comments were noted down: “we got a lot of results in a short time”, “a good and effective way of working”, “the group size was adequate”, “the silent meeting stages gave an opportunity to consider the tasks profoundly” and “the quiet participants got their opinions heard”.

Overall, the comments of the participants were positive. In addition, Eksote has used GDSS in other development workshops after this case, which indicates high satisfaction with the process and the achieved results.

On the basis of the experiences from the case, the presented collaboration process can be seen as a suitable way to promote the generation, evaluation and selection of development projects. The process offers a systematic way to assess strategic plans, it facilitates the collection of opinions from different experts, and the logic behind the decisions made is documented well.

The developed process could be improved, however, by dividing the GDSS meetings into different parts, because going through many tasks in the same meeting is very laborious. For example the first GDSS meeting could have been arranged on two different days. Another uncertainty is the quality of the results; did the group find the most important and ‘right’ development projects? Anyway, the group was satisfied with the work done, and decisions for further actions were made.

Conclusions

Integration of care is a challenge that organisations in the health and social services sector are currently facing. The development of integrated processes and organisations is a task that requires cross-functional commitment at all levels of the organisation. These types of collaboration processes are usually difficult, and thus advanced approaches are needed to increase their efficiency and effectiveness.

In this paper, a GDSS-supported collaboration process for defining projects to implement an integrated social and health care service strategy for the South Karelia District of Social and Health Services-organisation was introduced. The main result of the collaboration process was a detailed roadmap for the transition towards an integrated organisation. The process was divided into four phases, two of which were supported by a specific GDSS software.

The GDSS-based approach proved to be successful in supporting the creation of the roadmap. The utilised tool made it possible for the participants to discuss and analyse a large number of issues and tasks in a short period of time. Furthermore, anonymity of the participants in electronic discussion resulted in more open communication in the group. The GDSS-assisted collaboration process seemed to ensure a high level of commitment to the created plans in the group. Commitment, in turn, is essential to ensure that the created plans are implemented in practice.

According to the case experiences it seems likely that the developed process can also work in other strategy implementation problems of similar kind. There are several characteristics in the developed collaboration process that are likely to promote the strategy implementation. Identified general characteristics are for example: careful preplanning of the collaboration, systematic handling of meeting phases, effective facilitation of a group of experts from different units, possibility for equal participation, automatic documentation of the input, and possibility to work anonymously.

Reviewers

Leonid Chechurin, Professor, Head of Innovation Theory Department, St. Petersburg State Polytechnic University, Russia

Teija Hammar, RN, DSc (health economics), Senior Researcher, National Institute for Health and Welfare, Helsinki, Finland

Sirkka Sinkkonen, PhD, emerita professor in Health Services Management, Department of Health and Social Management, University of Eastern Finland (until 1.10.2010 University of Kuopio)

Helena Taskinen, PhD, Senior Researcher, University of Eastern Finland, Finland

Figures and Tables

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Table 1.

Benefits of the GDSS [12, 13]

Table 2.

Process chart of the structure of the first GDSS meeting

Table 3.

Process chart of the structure of the second GDSS meeting