Trial and error, together: divergent thinking and collective learning in the implementation of integrated care networks
| Author | Jenna M. Evans,Agnes Grudniewicz,Peter Tsasis |
| Published date | 01 September 2018 |
| Date | 01 September 2018 |
| DOI | http://doi.org/10.1177/0020852318783063 |
| Subject Matter | Special issue on Making connections: Hybrid networks and public action, Guest editors: Nassera Touati and Deena WhiteSpecial Issue Articles |
Review of
Administrative
Article
Sciences
International Review of
Trial and error, together:
Administrative Sciences
2018, Vol. 84(3) 452–468
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divergent thinking and
The Author(s) 2018
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collective learning in
DOI: 10.1177/0020852318783063
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the implementation of
integrated care networks
Jenna M. Evans
Institute of Health Policy, Management & Evaluation,
University of Toronto, Canada
Agnes Grudniewicz
Telfer School of Management, University of Ottawa, Canada
Peter Tsasis
School of Health Policy and Management, York
University, UK
Abstract
Hybrid networks that link disparate professionals and organizations are a common
approach to deliver integrated care to patients. Recent literature argues that successful
implementation of these networks demands a socio-cognitive perspective in which
stakeholder mental frames and thought processes are prioritized, investigated, and
compared. The aims of this article are to identify where mindsets diverge among clinical
and managerial stakeholders involved in the implementation of integrated care net-
works known as ‘Health Links’ (HLs) in Ontario, Canada, and to describe strategies
to support stakeholders’ capacity to collectively learn and develop more convergent
views. Drawing from shared mental model theory and practice-based learning theory, a
secondary analysis was conducted of interview data with 55 healthcare professionals
and managers involved in the implementation of HLs. We identified examples of diver-
gences in stakeholders’ conceptualization of the HL design and approach (‘strategy
Corresponding author:
Jenna M. Evans, Institute of Health Policy, Management & Evaluation, Dalla Lana School of Public Health,
University of Toronto, Health Sciences Building, 155 College Street, Suite 425, Ontario M5T3M6, Toronto.
Email: jenna.evans@utoronto.ca
Evans et al.
453
mental model’) and their perceptions of each other and how they work together
(‘relationship mental model’). We also identified four strategies that facilitate
learning and possibly mental model convergence. The results of the study may
help guide stakeholder dialogue towards collective learning and coordinated action
for integrated care delivery.
Points for practitioners
The findings suggest that in the implementation of large-scale change involving multiple
stakeholder groups, there are predictable areas where divergent views are likely to
occur and may have a negative impact on coordinated action. An awareness of these
potential divergences can guide practitioners to examine them explicitly and
regularly, and to proactively develop strategies to support practice-based learning
and the development of a convergent perspective.
Keywords
healthcare, hybridity, implementation, integrated care, learning, networks, policymak-
ing, shared mental models
Introduction
Healthcare delivery is largely organized by specialization and composed of inde-
pendent professions and organizations that rarely function as a unified system
(Glouberman and Mintzberg, 2001). This fragmentation is problematic for
patients with complex healthcare needs such as those with multiple chronic
conditions. These patients require services from numerous professionals across
diverse care settings such as primary care clinics, hospitals, specialist clinics,
long-term care facilities, and social service agencies (Bodenheimer, 2008).
Frequent transitions across care settings contribute to inconsistent patient moni-
toring, duplicative tests, delays in diagnosis, and medication errors, which can
threaten patient safety, quality of care, and health outcomes (Bodenheimer,
2008). Patients with complex healthcare needs thus require care that is integrated
across professionals and settings over time (Singer et al., 2011).
While a fully integrated healthcare system where professionals and organiza-
tions share a single mission, resources, and patient information is ideal (e.g. Kaiser
Permanente), it is often challenging or impossible to achieve (Denis et al., 2011).
Instead, most healthcare systems introduce new policies, financial incentives, and
one-time grants to stimulate the development of hybrid networks that link disparate
healthcare professionals and organizations (Evans et al., 2013). The term ‘hybrid
network’ refers to an entity that links different sectors, organizations, and/or
stakeholders with diverse and often conflicting belief systems and practices (i.e.
institutional logics) (Skelcher and Smith, 2015; Thornton and Ocasio, 2008).
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International Review of Administrative Sciences 84(3)
Prominent examples of hybrid integrated care networks include Accountable Care
Organizations and Patient-Centered Medical Homes in the US, and Integrated
Care Pilots in England. Hybrid integrated care networks have demonstrated a
range of positive outcomes, including reduced emergency department (ED) visits
and nursing home placements, lower institutional costs, higher patient satisfaction
and improved health outcomes (Bardsley et al., 2013; Curry and Ham, 2010;
Ouwens et al., 2005; Wodchis et al., 2015). However, there is considerable vari-
ability in the success of hybrid integrated care networks, and the literature con-
tinues to emphasize the challenges in cultivating collaboration across diverse
stakeholder groups (Kreindler et al., 2012; Ling et al., 2012; Pate et al., 2010;
Tsasis et al., 2013; Williams and Sullivan, 2009).
Delivering integrated care requires organizations and professionals to work
together in a coordinated fashion, sharing relevant medical information and
making care decisions that are consistent with and informed by the care delivered
by other professionals (Singer et al., 2011). The literature suggests that integrated
care delivery requires not only structural and process improvements, but also
change in the mindsets and behaviours of stakeholders such as managers and
healthcare professionals (Denis et al., 2011; Evans and Baker, 2012; Ferlie et al.,
2005). In order to deliver integrated care, stakeholder perceptions of their roles,
relationships, and practices must evolve alongside clinical, organizational and
environmental changes (Denis et al., 2011). Perceptions play an integral role in
the delivery of integrated care because they provide the underlying logic for action
(Walsh, 1995). As such, the successful implementation of hybrid integrated care
networks demands a socio-cognitive perspective in which stakeholder perceptions
are prioritized, investigated, and compared (Evans and Baker, 2012). If stakehold-
ers have conflicting ideas about the services to be integrated, the steps and partners
involved, or the underlying purpose, they may be working towards different
visions and their interactions may be disorganized and unproductive (Evans and
Baker, 2012).
Research across disciplines confirms the importance of shared views in the
execution of coordinated action and has used a variety of terms to capture this
phenomenon, including ‘strategic consensus’ (Kellermanns et al., 2011), ‘cross-
understanding’ (Huber and Lewis, 2010), ‘common ground’ (Dewulf et al.,
2011), ‘congruent understandings’ (Vlaar et al., 2006), and ‘shared framing’
(Fiol, 1994). In public administration, synthesizing the perspectives of diverse
actors is a common challenge, particularly in the implementation of initiatives –
like integrated care – that require coordinated action (Dewulf et al., 2011; Rein and
Schon, 1996). Although numerous studies of integrated care involve comparing
stakeholder perspectives, divergences in views have been identified and reported
using varied methods and language (Jiwani and Fleury, 2011; Kreindler et al.,
2012; Ling et al., 2012; Pate et al., 2010; Tsasis et al., 2013; van Wijngaarden
et al., 2006; Williams and Sullivan, 2009). The lack of consistency across studies
makes it challenging to communicate and accumulate knowledge regarding diver-
gent mindsets. For example, we lack knowledge regarding which divergences in
Evans et al.
455
understanding are most common and impactful, and what strategies leaders can
use to facilitate convergence of thinking across stakeholder groups involved in
integrating care. The Integration Mindsets Framework was developed to support
the conceptual and empirical advancement of this line of inquiry (Appendix A)
(Evans et al., 2014a).
The Integration Mindsets Framework draws from theory, empirical evidence,
and practice to identify key areas where a lack of shared understanding may sig-
nificantly hamper efforts to integrate care (Evans et al., 2014a). The distinguishing
feature of the framework is its roots in industrial psychology, specifically shared
mental model theory. In the literature on integrated care, cultural differences are
often offered as explanations for failed or suboptimal initiatives (e.g. Friedman
and Goes, 2001; Pate et al., 2010; Suter et al., 2009). An alternative approach to the
dominant focus on general cultural attributes is to examine individual and shared
mental models specific to integrated care.
The aim of this article is twofold. First, we identify where mindsets diverge
among clinical and managerial stakeholders involved in the implementation of
hybrid integrated care networks known as ‘Health Links’ (HLs) in Ontario,
Canada, and map these divergent mindsets on to the Integration Mindsets
Framework. Second, we identify strategies from the HLs case that may enhance
stakeholders’ capacity to learn and develop more convergent views.
Theories: shared mental models and practice-based...
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